The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?
Every 30 minutes
Every 180 minutes
Every 60 minutes
Every 120 minutes
The Correct Answer is D
A. Changing the patient's position every 30 minutes can help prevent pressure sores but this is such a short interval. The recommended interval is at least every 2 hours.
B. Every 180 minutes (or every 3 hours) is too long of an interval between position changes for a patient at risk for skin impairment. Prolonged pressure on bony
prominences increases the risk of pressure ulcer development.
C. Every 60 minutes (or every hour) is more frequent than every 180 minutes but may
still not be sufficient for preventing pressure ulcers in an unconscious patient with limited mobility.
D. For an unconscious patient at risk for skin impairment, it is recommended to reposition the patient at least every two hours to prevent pressure ulcers and skin breakdown. This frequency is a balance between providing adequate skin protection and minimizing the risk of injury to the patient or strain to the healthcare provider.
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Related Questions
Correct Answer is B
Explanation
A. Standing close to the patient is a recommended practice to maintain proximity and control during patient transfers. This action is appropriate and does not require
intervention.
B. Twisting at the torso can lead to strain or injury to the nurse's back. It is essential to avoid twisting while performing patient transfers to maintain proper body mechanics and prevent injury.
C. Maintaining a wide base of support is important for stability and balance during patient transfers. This action is appropriate and promotes safe transfer techniques.
D. Using proper body mechanics is crucial for preventing injury during patient transfers.
However, the specific concern in this scenario is twisting at the torso, which can lead to strain or injury, rather than overall body mechanics.
Correct Answer is B
Explanation
The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. The rationale for this answer is based on the clinical findings noted in the nurse's notes. The presence of a reddened area on the client's calf, along with a difference in calf circumference between the left and right legs,suggests the possibility of deep vein thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, typically in the legs. This can lead to a pulmonary embolism if a part of the clot breaks off and travels to the lungs, blocking blood flow. The client's recent long-duration car trip could have contributed to the development of DVT, as prolonged immobility is a known risk factor. The client's high fiber diet and adequate fluid intake are more likely to prevent constipation, and there is no indication of lead exposure, breath sounds issues, or atherosclerosis based on the information provided. Therefore, the most appropriate selections are 'pulmonary embolism' for the condition and 'possible deep vein thrombosis' for the client finding.
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