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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Noodles:

Noodles by themselves are typically a carbohydrate source and are lower in fat. However, it's essential to consider how they are prepared. If they are served with a high-fat sauce or other fatty ingredients, they may contribute to a higher fat intake.

B. Vegetable soup:

Vegetable soup, particularly if it is broth-based and contains a variety of vegetables, can be a healthy and lower-fat option. It provides vitamins, minerals, and fiber without a significant amount of fat.

C. Baked fish:

Baked fish is a lean source of protein and is generally lower in fat compared to fried or heavily processed options. The key is in the preparation method; baking is a healthier option than frying. However, it's essential to avoid high-fat toppings or sauces.

D. Cheddar cheese:

Cheddar cheese is a high-fat dairy product. Individuals with a history of pancreatitis are often advised to limit their fat intake, and high-fat foods like cheddar cheese can exacerbate symptoms. It's recommended to choose lower-fat or fat-free dairy alternatives.

A. Provide an antiemetic. B. Make the client NPO. C. Administer a stimulant laxative. D. Auscultate bowel sounds.

Correct Answer is D

Explanation

A. Provide an antiemetic.

While providing an antiemetic can help alleviate the client's nausea and vomiting, it is not the priority action. Assessment should come first to determine the underlying cause.

B. Make the client NPO.

Making the client NPO might be necessary if there is concern about bowel obstruction or other gastrointestinal issues, but this decision should be based on an initial assessment, such as auscultating bowel sounds.

C. Administer a stimulant laxative.

Administering a stimulant laxative is not appropriate at this stage without first assessing bowel sounds. It could potentially worsen the situation if there is a bowel obstruction.

D. Auscultate bowel sounds.

The priority in this situation is to assess for possible complications such as bowel obstruction or paralytic ileus, which can occur postoperatively and can be exacerbated by opioid use. Auscultating bowel sounds helps determine the presence of normal, hypoactive, or absent bowel sounds, guiding further management.

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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?

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