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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Deep vein thrombosis (DVT) is a condition characterized by the formation of blood clots in deep veins, commonly occurring in the lower extremities. DVT can be acquired during hospitalization due to factors such as immobility, surgery, or certain medical treatments.
B. Hypothyroidism, diabetes mellitus, and hypertension are chronic medical

conditions that may be managed or exacerbated during hospitalization but are not typically considered hospital-acquired injuries. They are often present before
hospitalization and may require ongoing management during the hospital stay.

C. Diabetes mellitus is a chronic condition characterized by elevated blood sugar levels due to either insufficient insulin production or the body's inability to use
insulin effectively. While diabetes management may be necessary during

hospitalization, it is not considered a hospital-acquired injury. Instead, it is a pre- existing condition that requires ongoing monitoring and treatment.

D. Hypertension, or high blood pressure, is a chronic condition that may require management during hospitalization but is not typically considered a hospital- acquired injury. Hypertension is often managed with medications and lifestyle modifications and may be monitored and treated during the hospital stay.

A. Tell the family that someone should plan to stay with the client. B. Place the client in a quiet room at the end of the hallway. C. Keep the client's personal items within reach. D. Provide bright lighting in the client's room at night.

Correct Answer is C

Explanation

C. Keep the client's personal items within reach.Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.

Incorrect options:

A. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.

B. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.

D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.

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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?

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