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 A
A. Elevating the head of the bed helps to reduce pressure on bony prominences, especially the sacral area, and can help prevent pressure ulcers. However, the head of the bed should not be elevated more than 30 degrees to 45 degrees to maintain skin integrity.
B. Using a transfer device is important for moving the client safely, but it is not specifically related to maintaining skin integrity.
C. Massaging the skin over bony prominences is not recommended as it can increase friction and shear, which can contribute to pressure ulcer development.
D. Applying cornstarch is not typically recommended for pressure ulcer prevention. It can create a moist environment that may contribute to skin breakdown, especially in areas where moisture can become trapped.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Initiative vs. guilt is the developmental stage for children aged 3 to 6 years, where they begin to assert control and power over their environment. This stage is not applicable for a 9-year-old child.
B. Autonomy vs. shame and doubt is relevant for children aged 1 to 3 years. This stage focuses on children developing a sense of personal control over physical skills and a sense of independence, which is not directly relevant to a 9-year-old.
C. Identity vs. role confusion typically applies to adolescents aged 12 to 18 years, where individuals explore their independence and develop a sense of self and personal identity, making it less relevant for a 9-year-old child.
D. Industry vs. inferiority is the stage for children aged 6 to 12 years, where they develop a sense of pride in their accomplishments and abilities. During this stage, children are learning to cope with new social and academic demands, making it essential for the nurse to consider the child's self-esteem and competence in managing their asthma and engaging in age-appropriate activities. This stage directly relates to the planning of home care for the 9-year-old child with asthma.
Correct Answer is ["B","C","E"]
Explanation
A. Obtaining the provider's signature within 8 hours is not applicable to telephone orders.
This action is typically relevant to written orders.
B. Question any part of the order that is unclear or inappropriate. This helps ensure that the nurse fully understands the prescription and can catch any potential errors or discrepancies.
C. Transcribe the order into the client's health record. This step is crucial for documentation and to ensure that all members of the healthcare team have access to the prescribed treatment.
D. Implement a recorded order message if the nurse can hear and understand it clearly.
This is important to have a clear and accurate record of the provider's prescription, especially if there is any ambiguity in the verbal communication.
E. Repeating the order back to the provider is an effective method to confirm accuracy. This read-back process helps to verify that the nurse has understood the prescription correctly, reducing the potential for errors.
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