A nurse is providing discharge teaching to a caregiver about preventing pressure ulcers in a bedridden patient. Which statement by the caregiver indicates a need for further teaching?

“I will reposition every 2 hours to prevent pressure injuries."

“I should apply warm compresses to any red areas to improve circulation and prevent ulcers."

“I will encourage a diet rich in vitamin C, zinc, and protein to support skin healing."

“I should use foam cushions and heel protectors to relieve pressure on bony prominences."

Answer and Explanation

The Correct Answer is B

A. “I will reposition every 2 hours to prevent pressure injuries." Repositioning every 2 hours is a key preventive measure to relieve pressure and reduce the risk of pressure ulcers. This is an appropriate statement and does not indicate a need for further teaching.

B. “I should apply warm compresses to any red areas to improve circulation and prevent ulcers." This statement indicates a need for further teaching. Applying warm compresses to reddened areas can actually worsen tissue damage by increasing moisture and promoting skin breakdown. Instead, pressure should be relieved from the area immediately.

C. “I will encourage a diet rich in vitamin C, zinc, and protein to support skin healing." A diet high in protein, vitamin C, and zinc helps support skin integrity and promotes wound healing, making this a correct statement.

D. “I should use foam cushions and heel protectors to relieve pressure on bony prominences." Foam cushions and heel protectors help redistribute pressure, reducing the risk of pressure ulcers on bony areas like the sacrum and heels. This statement does not indicate a need for further teaching.

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Correct Answer is C

Explanation

A. Have the nurse wear an N95 respirator during transport. While the nurse should wear an N95 respirator when providing direct care to a patient with TB in a hospital room, the focus during transport is on preventing airborne transmission from the patient to others.

B. Use a standard wheelchair with no additional precautions. Standard precautions are not sufficient for airborne diseases like TB. Without proper precautions, the patient may spread Mycobacterium tuberculosis to others during transport.

C. Have the patient wear a surgical mask during transport. A surgical mask on the patient helps contain respiratory droplets and prevents the spread of TB during transport. This is the standard precaution for transporting patients with airborne infections.

D. Place the patient in a negative-pressure isolation room during transport. Negative-pressure isolation rooms are used for patients while they are in the hospital room, not during transport. Negative pressure cannot be maintained in an open environment.

A. Assess for the presence of pedal pulses and capillary refill time. B. Measure the patient's calf circumference and compare it bilaterally. C. Ask the patient to flex and extend the affected foot to assess for range of motion. D. Check for redness and drainage at the pin sites of the external fixation device.

Correct Answer is A

Explanation

A. Assess for the presence of pedal pulses and capillary refill time: Compartment syndrome can lead to diminished or absent pulses, delayed capillary refill, and decreased circulation. Assessing pedal pulses and capillary refill is a crucial step in confirming the diagnosis.

B. Measure the patient’s calf circumference and compare it bilaterally: Measuring limb circumference can help assess swelling, but it is not the most critical assessment in this situation. Capillary refill and pedal pulses provide more immediate information about circulation.

C. Ask the patient to flex and extend the affected foot to assess for range of motion: Limited movement can be a sign of compartment syndrome, but if severe pain is already present, further movement may cause more damage. Assessing circulation should be prioritized first.

D. Check for redness and drainage at the pin sites of the external fixation device: Redness and drainage may indicate infection, but this does not directly assess for compartment syndrome. Circulatory assessment is more urgent.

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A nurse is providing discharge teaching to a caregiver about preventing pressure ulcers in a bedridden patient. Which statement by the caregiver indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to transport a patient with active tuberculosis (TB) to another department for a diagnostic procedure. Which of the following infection control precautions should the nurse implement?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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