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?
Place the client upright on a donut-shaped cushion.
Turn and reposition the client every 15 minutes while sitting.
Apply a moisture-barrier cream to the affected area.
Turn and reposition the client every 3 hours while in bed.
The Correct Answer is B
Choice A rationale: Donut-shaped cushions are contraindicated because they create a ring of high pressure that restricts blood flow to the central area. This can worsen tissue ischemia and accelerate skin breakdown.
Choice B rationale: Clients with paraplegia sitting in a chair should be repositioned every 15 minutes to relieve pressure. Frequent shifts are necessary because sitting exerts higher pressure on the ischial tuberosities than lying down.
Choice C rationale: Moisture-barrier creams are used to protect skin from incontinence or wound drainage. Nonblanchable erythema indicates a stage 1 pressure injury, which requires pressure relief rather than a topical moisture barrier.
Choice D rationale: While in bed, the standard of care is to turn and reposition the client at least every 2 hours. A 3-hour interval is too long and increases the risk of further tissue damage.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: A 10-year budget is impractical for cost containment, as healthcare costs fluctuate due to economic and technological changes. Long-term budgets lack flexibility for staffing or equipment needs, making them ineffective for ensuring cost-effective care delivery in dynamic healthcare environments.
Choice B reason: Hiring travel nurses increases costs due to high salaries and agency fees compared to permanent staff. While addressing short-term shortages, it does not promote long-term savings, as temporary labor is expensive, contrasting with strategies like workforce planning for cost containment.
Choice C reason: Reducing training programs may lower short-term costs but risks errors and lawsuits, increasing long-term expenses. Well-trained staff improve efficiency and outcomes, reducing readmissions. Training is critical for cost containment, as it enhances care quality in healthcare settings.
Choice D reason: Electronic health records (EHRs) reduce long-term costs by streamlining documentation and improving care coordination. EHRs enhance billing accuracy and reduce errors, offsetting initial costs with decreased administrative burdens and better patient outcomes, aligning with evidence-based cost containment strategies in healthcare.
Correct Answer is C
Explanation
Choice A reason: Preventing leakage is not the primary purpose of flushing an intermittent infusion device. Flushing maintains patency by clearing blood or medication residue, preventing clots or blockages. Leakage is addressed by proper capping or clamping, not flushing, making this statement incorrect as it misrepresents the procedure’s purpose.
Choice B reason: Flushing an infusion device does not contribute to hydration, as the flush solution (typically saline) is minimal and not intended for fluid replacement. The purpose is to maintain catheter patency by clearing debris or clots. This statement is incorrect, as it inaccurately suggests a hydration benefit unrelated to the procedure.
Choice C reason: Flushing an intermittent infusion device with saline clears blood or medication residue from the catheter, preventing occlusion and maintaining patency. Blood left in the line can clot, increasing infection risk or blocking the device. This statement accurately reflects the procedure’s purpose, ensuring continued functionality for future medication administration.
Choice D reason: Flushing does not ensure sterility, as the device is already in place and exposed to the bloodstream. Sterility is maintained during insertion or access, not flushing. The primary goal is patency, not sterilization, making this statement incorrect as it misaligns with the procedure’s clinical purpose.
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