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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is D
Explanation
The total volume to infuse is 1,000 ml over 8 hours, which calculates to a rate of 125 ml/hour (1,000 ml ÷ 8 hr).
- By 1400, the client has already received 500 ml (since there is 500 ml remaining in the IV bag).
- The infusion has been running for 4 hours (from 1000 to 1400), which means the nurse has infused 500 ml (125 ml/hour × 4 hours).
- Since there are 500 ml remaining in the bag, it will take another 4 hours to complete the infusion (500 ml ÷ 125 ml/hour).
- Therefore, if the nurse administers the next bag immediately after the current one runs out, it will be at 1800 (1400 + 4 hours).
- However, the timing of administering the next bag depends on when the current bag will run out. Since there is still 500 ml remaining, it will take 4 more hours until the IV solution runs out, which is at 1800.
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