A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?
Use an air-assisted device.
Position the bed in reverse Trendelenburg.
Elevate the head of bed to a 45° angle.
Lower the bed close to the ground.
The Correct Answer is A
A. Use an air-assisted device.
Using an air-assisted device, such as a hover mat or air mattress, is an appropriate measure when repositioning a client with a pressure ulcer. These devices help reduce friction and shear forces, minimizing the risk of further skin breakdown. It also aids in maintaining the skin's integrity during movement, making it a suitable choice for the prevention of pressure ulcers.
B. Position the bed in reverse Trendelenburg:
Positioning the bed in reverse Trendelenburg involves raising the foot of the bed higher than the head. This position is not specifically related to pressure ulcer prevention or repositioning. It may be used for other medical reasons, but it does not directly address the issue of pressure ulcer care.
C. Elevate the head of bed to a 45° angle:
While elevating the head of the bed is commonly used for various reasons, including respiratory support or preventing aspiration, it may not be directly related to the repositioning of a client with a pressure ulcer. The angle mentioned (45°) is not specifically associated with pressure ulcer care.
D. Lower the bed close to the ground:
Lowering the bed close to the ground may be a safety measure to prevent injuries from falls, but it does not address the specific needs of repositioning a client with a pressure ulcer. The focus in pressure ulcer care is typically on using appropriate devices and techniques to minimize friction and pressure on vulnerable areas of the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.2"]
Explanation
To give a client with rheumatoid arthritis a subcutaneous dose of methotrexate 7.5 mg, the nurse needs to calculate the correct volume of the drug solution.
The drug solution has a concentration of 15 mg/0.4 mL, which means that 0.4 mL of the solution contains 15 mg of methotrexate. To find the volume of the solution that contains 7.5 mg of methotrexate, the nurse can use a proportion:
- 15 mg/0.4 mL = 7.5 mg/x mL
Cross-multiplying and solving for x gives:
- x = (0.4 mL x 7.5 mg) / 15 mg
- x = 0.2 mL
Therefore, the nurse should administer 0.2 mL of the drug solution to deliver 7.5 mg of methotrexate subcutaneously.
Correct Answer is ["2.1"]
Explanation
To calculate the total daily dose of tobramycin, we use the formula:
- Total Daily Dose (mg) = Dose (mg/kg/day) × Weight (kg)
- Total Daily Dose (mg)=Dose (mg/kg/day)×Weight (kg)
In this case:
- Total Daily Dose=3 mg/kg/day × 85 kg
- Total Daily Dose=255mg/day
Since the total daily dose is divided into three doses, the nurse should administer:
- Dose per Administration =Total Daily Dose/Number of Doses per Day
- Dose per Administration = 255 mg/3
- Dose per Administration≈85mg
Now, to calculate the volume (mL) to administer, we use the concentration of the available tobramycin solution:
- Volume (mL)=Dose per Administration (mg)/Concentration (mg/mL)
In this case:
- Volume=85mg/40mg/mL
- Volume≈2.1mL
Therefore, the nurse should administer approximately 2.1 mL of tobramycin per dose, rounded to the nearest tenth.
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