A nurse is planning care for an older adult client who is at risk for developing pressure ulcers.
Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
Elevate the head of the bed no more than 45°.
Use a transfer device to lift the client up in bed.
Massage the skin over the client's bony prominences.
Apply cornstarch to keep sensitive skin areas dry.
The Correct Answer is B
A. The head of the bed should generally be elevated no more than 30° to reduce shear and friction, not 45°.
B. Using a transfer device to lift the client prevents shearing and friction, which helps maintain skin integrity and reduces the risk of pressure ulcers.
C. Massaging bony prominences is not recommended, as it can damage underlying tissue and increase risk of ulcer formation.
D. Cornstarch is not advised because it can create a moist environment that promotes skin breakdown and infection.
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Related Questions
Correct Answer is C
Explanation
A. The nurse is not responsible for obtaining informed consent. This is the responsibility of the healthcare provider performing the procedure, who must explain the risks, benefits, and alternatives to the client. The nurse may assist in ensuring the client has the necessary information, but the final responsibility for obtaining consent lies with the provider.
B. Explaining the risks and benefits of the procedure is part of the informed consent process.
The client needs to be informed about potential risks, benefits, and alternatives before giving consent.
C. This is correct. The nurse's role in the informed consent process is to witness the client's signature after the healthcare provider has explained the procedure, risks, and benefits. The nurse verifies that the client is signing voluntarily and understands the consent form, but the nurse does not provide the explanation.
D. Explaining the procedure to the client if they do not understand is essential for ensuring that the client has sufficient information to make an informed decision. This should be done in a clear and understandable manner.
Correct Answer is B
Explanation
A. An elevation in the red blood cell (RBC) count is not a specific indication of infection. It primarily reflects oxygen-carrying capacity.
B. An elevation in the white blood cell (WBC) count is an indication of infection. When the body is fighting an infection, the number of white blood cells increases as part of the immune response.
C. Potassium is an electrolyte and is not a specific marker for infection. Abnormal potassium levels may indicate a variety of conditions, but they do not directly indicate infection.
D. Blood urea nitrogen (BUN) is a marker of kidney function and is not a specific indicator of infection. Elevated BUN levels can be seen in various kidney and non-kidney-related conditions.
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