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 C
Explanation
A. Disinfecting hands using an alcohol-based waterless antiseptic is not effective against Clostridium difficile spores. C. difficile is a bacterium that forms spores, which are resistant to alcohol-based hand sanitizers. Handwashing with soap and water is recommended for effective removal of the spores.
B. Wearing an N95 respirator is not specifically indicated for caring for clients with Clostridium difficile. The primary mode of transmission for C. difficile is fecal-oral, and standard precautions, including gloves and gowns, are usually sufficient. N95 respirators are more commonly used for airborne precautions.
C. Using diluted bleach to clean soiled equipment is the correct instruction. Clostridium difficile spores are resistant to many disinfectants, but bleach (sodium hypochlorite) is effective in killing C. difficile spores. Diluted bleach solutions are recommended for cleaning surfaces and equipment that may be contaminated with C. difficile.
D. Providing a room with negative-pressure airflow is not typically necessary for clients with Clostridium difficile. Standard precautions, including appropriate cleaning and disinfection, are generally sufficient to prevent the spread of C. difficile in healthcare settings.
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.
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