A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?
Assess pressure points every 24 hr.
Turn and reposition the client every 3 hr while in bed.
Teach the client to shift his weight every 15 min while sitting.
Place the client upright ona donut-shaped cushion.
The Correct Answer is C
Rationale:
A. Assess pressure points every 24 hr: Skin assessment should be performed at least every shift or more frequently in high-risk clients. Waiting 24 hours between assessments increases the risk of progression from erythema to ulceration due to unrelieved pressure.
B. Turn and reposition the client every 3 hr while in bed: Clients at risk for pressure injuries should be repositioned at least every 2 hours in bed to promote circulation and reduce tissue ischemia. Extending this interval to 3 hours is inadequate for prevention or healing.
C. Teach the client to shift his weight every 15 min while sitting: Teaching the client to perform weight shifts every 15 minutes reduces pressure on the ischial areas, promoting blood flow and preventing further skin breakdown. This intervention empowers self-care and is a key preventive strategy for wheelchair-bound clients.
D. Place the client upright on a donut-shaped cushion: Donut cushions can impair circulation around the pressure site by concentrating pressure on surrounding tissue, worsening ischemia and tissue damage. Pressure-redistribution cushions or gel pads are safer alternatives.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Assess pressure points every 24 hr: Skin assessment should be performed at least every shift or more frequently in high-risk clients. Waiting 24 hours between assessments increases the risk of progression from erythema to ulceration due to unrelieved pressure.
B. Turn and reposition the client every 3 hr while in bed: Clients at risk for pressure injuries should be repositioned at least every 2 hours in bed to promote circulation and reduce tissue ischemia. Extending this interval to 3 hours is inadequate for prevention or healing.
C. Teach the client to shift his weight every 15 min while sitting: Teaching the client to perform weight shifts every 15 minutes reduces pressure on the ischial areas, promoting blood flow and preventing further skin breakdown. This intervention empowers self-care and is a key preventive strategy for wheelchair-bound clients.
D. Place the client upright on a donut-shaped cushion: Donut cushions can impair circulation around the pressure site by concentrating pressure on surrounding tissue, worsening ischemia and tissue damage. Pressure-redistribution cushions or gel pads are safer alternatives.
Correct Answer is D
Explanation
Rationale:
A. Apply a cool pack to the perineum: Cool packs are useful for reducing perineal swelling and discomfort after delivery, not during the latent phase of labor. At this stage, the client benefits more from relaxation and distraction techniques that help manage early contractions.
B. Encourage the client to use pant-blow breathing: Pant-blow or patterned breathing is recommended during the transition phase of labor, when contractions are intense and close together. In the latent phase, the client typically uses slow, relaxed breathing to conserve energy and remain calm.
C. Have their support person leave the room when the doula arrives: Both the doula and the support person play complementary roles in providing emotional and physical support. Asking the partner to leave can increase anxiety and reduce the sense of safety.
D. Lightly stroke the abdomen during contractions: Light abdominal stroking, known as effleurage, promotes relaxation and distraction from contraction pain during the latent phase. This technique aligns with natural childbirth methods by using soothing touch to reduce tension and enhance comfort without pharmacologic intervention.
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