A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?
Massage the client’s bony prominences.
Keep the head of the bed elevated.
Reposition the client at least every 2 hr.
Keep the client’s skin moist.
The Correct Answer is C
A. Massage the client’s bony prominences:
Massaging bony prominences is generally not recommended for individuals at risk for pressure ulcers. Massage can increase friction and shear forces on the skin, which may contribute to skin damage rather than prevent it. Gentle, careful handling of the skin is preferable.
B. Keep the head of the bed elevated:
While elevating the head of the bed may be appropriate for certain medical conditions, it is not a primary preventive measure for pressure ulcers. In fact, keeping the head of the bed elevated continuously can contribute to pressure on the sacrum and coccyx, increasing the risk of pressure ulcers in those areas.
C. Reposition the client at least every 2 hr:
Regular repositioning is a crucial preventive measure for pressure ulcers. Repositioning helps redistribute pressure, improves blood flow to vulnerable areas, and reduces the risk of skin breakdown.
D. Keep the client’s skin moist:
While maintaining skin moisture is important to prevent dryness and cracking, excessive moisture can contribute to skin breakdown. The emphasis should be on keeping the skin clean and dry, with the use of moisturizers applied judiciously to prevent excessive dryness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. “Turn each of your hands and forearms so your palm is facing down.”
This describes pronation, not supination. In pronation, the palm faces down, and the radius crosses over the ulna.
B. “Take each of your hands and touch your shoulders.”
This describes flexion at the elbow joint, not supination. Flexion involves decreasing the angle between body parts.
C. “Turn each of your hands and forearms so your palm is facing up.”
This is the correct choice. Supination involves turning the hands and forearms so that the palms face up, and the radius and ulna are parallel.
D. “Move each of your arms to rest at your sides.”
This describes adduction, bringing the arms back to the sides of the body, not supination.
Correct Answer is B
Explanation
A. Ensure the rope knots are away from the pulleys.
While ensuring that rope knots are away from the pulleys is a general principle in traction care to maintain proper functioning, it is not directly related to the specific positioning of the child's feet in Buck's traction.
B. Ensure the child’s feet are against the footboard.
This statement is correct. Ensuring that the child's feet are against the footboard helps maintain proper hip alignment and prevent complications such as contractures. It is an important aspect of care when managing Legg-Calve-Perthes disease in Buck's traction.
C. Apply antibiotic ointment to the pin sites daily.
This action is not applicable to Buck's traction. Buck's traction involves the use of a boot or splint, and it does not include pins or pin sites. The use of antibiotic ointment for pin sites is more relevant in the context of skeletal traction.
D. Reduce the child’s fluid intake.
There is no indication to reduce the child's fluid intake specifically in the context of Buck's traction. Adequate hydration is generally important for overall health, and fluid restriction is not a standard practice for managing Legg-Calve-Perthes disease in Buck's traction.
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