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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. To help the nurse validate the client’s reports of pain
This option suggests that the nurse's actions (straightening bed linens, rubbing the back, assisting with repositioning) are intended to assess or confirm the client's reports of pain. However, these actions are more aligned with providing comfort and assistance with activities of daily living rather than specifically assessing pain. If the client reports pain related to the chest tube, a more focused assessment and intervention would be needed.
B. To increase positive pressure in the chest
This option implies that the nurse's actions could somehow influence the positive pressure in the client's chest, which is not accurate. Positive pressure in the chest is usually related to mechanical ventilation or specific medical interventions. The described actions are more related to comfort and assistance with daily activities.
C. To assist the client with ADLs (Activities of Daily Living)
This is the most appropriate choice. The nurse's actions, such as straightening bed linens, rubbing the back, and assisting with repositioning, align with providing support for the client's daily activities and overall well-being.
D. To modify the client’s perception of pain
This option suggests that the nurse's actions are aimed at altering the client's perception of pain. While comfort measures can contribute to pain management, these specific actions are not typically used to modify perception. If pain is a concern, more direct pain management strategies and assessments would be appropriate.
Correct Answer is B
Explanation
A. “Most of my calories each day should be from fats.”
This statement is not accurate. While fats are essential for a balanced diet, it is not recommended for the majority of calories to come from fats. The emphasis should be on a variety of macronutrients, including carbohydrates and proteins.
B. “I should eat more calories from complex carbohydrates than anything else.”
This is the correct choice. Individuals with diabetes are often encouraged to obtain the majority of their calories from complex carbohydrates. These include whole grains, vegetables, and legumes, which have a slower impact on blood glucose levels.
C. “Simple sugars are needed more than other calorie sources.”
This statement is not accurate for individuals with diabetes. Simple sugars can lead to rapid spikes in blood glucose levels and should be consumed in moderation.
D. “Protein should be my main source of calories.”
This statement is not accurate. While protein is important for overall health, it is not recommended for protein to be the main source of calories. A balanced diet with an emphasis on complex carbohydrates is typically recommended.
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