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. Clean the perineum from front to back.

After arranging the sterile items, the next step involves preparing the client for catheter insertion, which includes cleaning the perineum from front to back using appropriate techniques to minimize the risk of infection.

B. Lubricate the catheter.

Following the preparation of the client, the next step involves lubricating the catheter before insertion. Lubrication facilitates the smooth and atraumatic insertion of the catheter.

C. Explain to the client that she will feel temporary discomfort.

Providing information and preparing the client for the procedure is an important aspect, but it typically follows the physical preparation steps. Explaining to the client about potential discomfort should be done before the procedure but after the necessary physical preparations are complete.

D. Arrange the sterile items on the sterile field.

This is the first action to be taken. It involves preparing all the necessary sterile items on a sterile field, ensuring that everything needed for the catheter insertion procedure is organized and ready to maintain aseptic technique.

A. Assign an assistive personnel to feed the client. B. Explain that the tray is here and place the client’s hands on the tray. C. Describe to the client the location of the food on the tray. D. Ask the client if she would prefer a liquid diet.

Correct Answer is C

Explanation

A. Assign an assistive personnel to feed the client.

This option involves assigning someone else to feed the client. While it may ensure that the client receives adequate nutrition, it does not promote independence. The client may prefer to feed themselves if given the opportunity.

B. Explain that the tray is here and place the client’s hands on the tray.

While explaining the presence of the tray is helpful, physically placing the client's hands on the tray is a more direct form of assistance. It takes away the opportunity for the client to explore and locate items independently.

C. Describe to the client the location of the food on the tray.

This is the correct choice. Describing the location of the food on the tray allows the client to use their remaining senses, such as touch and hearing, to independently locate and eat their food.

D. Ask the client if she would prefer a liquid diet.

This option is related to dietary preferences but does not directly address the issue of promoting independence in eating. It focuses more on the type of diet rather than the manner in which the client can independently manage their meals.

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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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