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 ["80"]
Explanation
To calculate the infusion rate in mL/hr for the gentamicin IV bolus, you can use the following formula:
Infusion Rate (mL/hr) = Volume (mL)/Time (hr)
In this case:
Infusion Rate=100 mL/1.25 hr
Infusion Rate=80mL/hr
Therefore, the nurse should ensure the IV pump is set to deliver 80 mL/hr for the gentamicin IV bolus, rounded to the nearest whole number.
Correct Answer is ["A","C","D"]
Explanation
Ensure the client wears nonskid slippers when walking around the house.
Explanation: Nonskid slippers provide better traction and stability, reducing the risk of slipping.
B.Attach full-length side rails to the client's bed.
Explanation: Side rails can pose a risk of entrapment and may not prevent falls. The use of side rails is associated with safety concerns, and their use should be carefully evaluated.
C.Install a raised toilet seat in the client's bathroom.
Explanation: A raised toilet seat makes it easier for the client to sit down and stand up, reducing the risk of falls in the bathroom.
D.Encourage an annual review of the medications the client is taking.
Explanation: Medication reviews help identify drugs that may increase the risk of falls or interactions that could affect balance or cognitive function.
E.Place throw rugs on uncarpeted floors in the client's home.
Explanation: Throw rugs can be tripping hazards, especially for older adults with mobility issues. It's safer to have clear, unobstructed pathways in the home.
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