What nursing interventions decrease the risk of pressure injuries? (Select all that apply.)
Padding hard surfaces
Keep head of bed (HOB) at or less than 30 degrees
Keep head of bed (HOB) elevated to 75 degrees
Have client sit in wheelchair as much as possible
Place pillows between bony surfaces.
Correct Answer : A,B,E
Choice A reason: Padding hard surfaces is a nursing intervention that decreases the risk of pressure injuries, because it reduces the pressure, shear, and friction on the skin and underlying tissues. Hard surfaces, such as bed rails, wheelchair arms, or footrests, can cause compression or irritation of the skin, especially over the bony prominences. Padding hard surfaces with foam, gel, or air cushions can provide protection and comfort for the client.
Choice B reason: Keeping head of bed (HOB) at or less than 30 degrees is a nursing intervention that decreases the risk of pressure injuries, because it prevents the sliding or shifting of the client in bed. Sliding or shifting can cause shear and friction on the skin, especially over the sacrum, coccyx, or heels. Keeping head of bed (HOB) at or less than 30 degrees can maintain the alignment and stability of the client in bed.
Choice C reason: Keeping head of bed (HOB) elevated to 75 degrees is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Elevating the head of bed (HOB) to 75 degrees can cause the client to slide or shift in bed, which can increase the shear and friction on the skin, as explained above. Elevating the head of bed (HOB) to 75 degrees can also increase the pressure on the sacrum, coccyx, or heels, which can impair the blood flow and oxygen delivery to the skin and tissues.
Choice D reason: Having client sit in wheelchair as much as possible is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Sitting in wheelchair as much as possible can cause prolonged pressure, shear, and friction on the skin and underlying tissues, especially over the ischial tuberosities, sacrum, coccyx, or heels. Sitting in wheelchair as much as possible can also reduce the mobility and activity of the client, which can affect the blood circulation and muscle tone.
Choice E reason: Placing pillows between bony surfaces is a nursing intervention that decreases the risk of pressure injuries, because it relieves the pressure, shear, and friction on the skin and underlying tissues. Bony surfaces, such as the ankles, knees, hips, or elbows, can cause compression or irritation of the skin, especially when they are in contact with each other or with the bed. Placing pillows between bony surfaces can provide cushioning and separation for the skin and tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Allowing the client to sleep to build up stamina is not the priority intervention, because it does not address the psychosocial needs of the client. Sleeping is a physiological need, not a psychosocial need. Sleeping may help the client recover physically, but it does not help the client cope emotionally or socially with the isolation.
Choice B reason: Maintaining a sixfoot distance from the client is not the priority intervention, because it does not enhance the psychosocial needs of the client. Maintaining a sixfoot distance from the client is a safety measure, not a psychosocial intervention. Maintaining a sixfoot distance from the client may help prevent the transmission of infection, but it does not help the client feel less lonely or isolated.
Choice C reason: Providing a timeframe for the isolation is not the priority intervention, because it does not enhance the psychosocial needs of the client. Providing a timeframe for the isolation is an informational intervention, not a psychosocial intervention. Providing a timeframe for the isolation may help the client understand the rationale and duration of the precautions, but it does not help the client feel more engaged or supported.
Choice D reason: Providing the client with diversional activities is the priority intervention, because it enhances the psychosocial needs of the client. Providing the client with diversional activities is a psychosocial intervention, not a physiological, safety, or informational intervention. Providing the client with diversional activities may help the client feel more entertained, stimulated, and connected with others, which can reduce the negative effects of isolation.
Correct Answer is D
Explanation
Choice A reason: These drugs kill the virus is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is inaccurate and misleading. Antiretroviral drugs do not kill the virus, but rather block or interfere with the enzymes or proteins that the virus needs to replicate or integrate into the host cells. Antiretroviral drugs can reduce the viral load, which is the amount of virus in the blood, but they cannot eliminate the virus completely.
Choice B reason: Only certain licensed drugs are effective is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is vague and incomplete. Antiretroviral drugs are licensed and approved by the regulatory authorities, such as the Food and Drug Administration (FDA), based on their safety and efficacy. However, not all licensed drugs are equally effective for all people with HIV, as the virus can develop resistance or mutation to some drugs over time. Therefore, the choice and combination of antiretroviral drugs may vary depending on the individual's viral genotype, drug history, and drug interactions.
Choice C reason: A few missed doses per month are OK is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is incorrect and dangerous. Antiretroviral drugs require strict adherence and compliance, which means taking the drugs exactly as prescribed, without missing or skipping any doses. A few missed doses per month are not OK, as they can reduce the effectiveness of the drugs and increase the risk of viral resistance or mutation, which can lead to treatment failure or disease progression.
Choice D reason: These drugs inhibit viral replication is true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it describes the mechanism and outcome of the drugs. Antiretroviral drugs inhibit viral replication, which means they prevent or slow down the multiplication or reproduction of the virus. Antiretroviral drugs can inhibit viral replication by targeting different stages of the viral life cycle, such as reverse transcription, integration, or maturation. Antiretroviral drugs can improve the immune function and quality of life of people with HIV.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.