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. “You should avoid the use of cell phones after the pacemaker is placed.”
This statement is not accurate. In general, the use of cell phones is considered safe for individuals with pacemakers. However, it is recommended to keep the phone on the opposite side of the pacemaker to minimize any potential interference.
B. “Swelling and redness of the operative site are normal findings for the first two days following the
procedure.”
This statement is partially accurate. Swelling and redness at the operative site can be expected immediately after the procedure. However, if these signs persist or worsen after the first two days, it may indicate a potential issue, and the healthcare provider should be notified.
C. “You will need to limit movement of the arm on the side of the pacemaker.”
This statement is accurate. Limiting movement of the arm on the side of the pacemaker is a standard precaution to prevent dislodgement of the leads and allow proper embedding of the pacemaker leads into the surrounding tissues.
D. “Hiccups following pacemaker placement are an expected response.”
This statement is not accurate. Hiccups are not typically associated with pacemaker placement. If the client experiences unexpected symptoms, such as hiccups, it is important to report them to the healthcare provider for further evaluation.
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.
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