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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dehydration is unlikely to cause blood-tinged urine. Dehydration can lead to concentrated urine, but it typically does not cause blood in the urine.
B. Pernicious anemia is a condition related to a deficiency in vitamin B12, which can lead to a decrease in red blood cell production. However, it is not directly associated with blood in the urine.
C. Bladder infection can cause blood in the urine, but it is more commonly associated with symptoms such as urinary frequency, urgency, and burning during urination. If blood is present, it is usually due to inflammation of the bladder lining.
D. Prostate enlargement, also known as benign prostatic hyperplasia (BPH), can cause blood-tinged urine. The prostate gland surrounds the urethra, and enlargement can lead to irritation and bleeding from the urinary tract.
Correct Answer is B
Explanation
A. Using a computer terminal in a non-public area is appropriate and helps maintain client confidentiality.
B. Sharing computer passwords with coworkers is a serious breach of client confidentiality and security. Each individual should have their own unique login credentials to ensure accountability and protect sensitive information.
C. Logging out of the computer before leaving a terminal is a standard practice to protect client information from unauthorized access.
D. Preventing an unidentified healthcare worker from viewing a health record on the computer screen is a responsible action to protect client confidentiality.
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