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 B
Explanation
A. Discontinue the client's PCA:
The discontinuation of the patient-controlled analgesia (PCA) may be necessary, but assessing the client's vital signs is a priority to ensure the client's overall stability and response to the surgery.
B. Measure the client's vital signs:
This is the correct answer. Assessing vital signs is a priority postoperatively to monitor the client's physiological status, detect any signs of complications, and guide further interventions.
C. Remove the client's indwelling urinary catheter:
Removing the urinary catheter may be part of the postoperative care plan, but it is not the immediate priority. Vital sign assessment is crucial for overall patient monitoring.
D. Change the client's abdominal dressing:
Changing the abdominal dressing is an important aspect of postoperative care, but assessing vital signs takes precedence to identify any signs of distress or instability.
Correct Answer is ["1.5"]
Explanation
To calculate the volume (mL) that the nurse should administer per dose, you can use the following formula:
Volume (mL) = Dose (mg)/Concentration (mg/mL)
In this case:
- Volume = 500 mg/ 330 mg/mL
- Volume≈1.5mL
Therefore, the nurse should administer approximately 1.5 mL per dose of cefazolin 500 mg IM.
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