The nurse is caring for a client who is at high risk for development of pressure injury.
The client is able to move independently, but has been placed on bedrest. The client has experienced two episodes of urinary incontinence. Which intervention(s) should the nurse include in the care plan? (SELECT ALL THAT APPLY)
Instruct client to shift their weight at least every 15 minutes
Keep head of bed raised at 45 degrees at all times
Massage over bony prominences every hour while awake
Apply moisture barrier cream to perineal skin
Consult with the wound care nurse about use of a specialty mattress
Correct Answer : A,D,E
Choice A rationale: Instructing the client to shift their weight at least every 15 minutes helps prevent pressure injuries.
Choice B rationale: Keeping the head of the bed raised at 45 degrees at all times is not a typical practice for preventing pressure injuries.
Choice C rationale: Massaging over bony prominences every hour while awake may not be recommended, as this can cause friction and shear, contributing to skin breakdown. Choice D rationale: Applying moisture barrier cream to perineal skin helps protect against skin breakdown from urinary incontinence.
Choice E rationale: Consulting with the wound care nurse about the use of a specialty mattress can provide additional support and help prevent pressure injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Shared responsibility is a necessary feature of a team, promoting collaboration and achievement of common goals.
Choice B rationale: Mutual independence allows team members to work together while maintaining individual contributions.
Choice C rationale: Working in the same department is not a necessary feature of a team. Teams can be effective regardless of their physical proximity.
Choice D rationale: Common purpose is essential for a team to work cohesively toward shared goals.
Correct Answer is D
Explanation
Choice A rationale: Norming is characterized by the development of group cohesion and establishment of norms, not necessarily high-level problem-solving.
Choice B rationale: Storming is marked by conflict and tension within the group, not optimal problem-solving.
Choice C rationale: Forming is the initial stage where members get to know each other; it does not represent a highly functioning team.
Choice D rationale: Performing is the stage where the group is functioning at its highest level, demonstrating effective problem-solving and productivity.
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