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 C
Explanation
Choice A reason: "In order to avoid flareups of Raynaud's, ensure to keep cool." is not a correct answer, because it can worsen the symptoms of Raynaud's phenomenon. Raynaud's phenomenon is a condition that causes the blood vessels in the fingers and toes to narrow and spasm in response to cold or stress, resulting in reduced blood flow and color changes. Keeping cool can trigger or aggravate the spasms and decrease the blood flow.
Choice B reason: "In order to avoid flareups of Raynaud's, ensure you wear sunscreen." is not a correct answer, because it is not related to Raynaud's phenomenon. Sunscreen is a protective measure for clients with lupus, who may have increased sensitivity to ultraviolet rays and increased risk of skin damage and flareups. However, sunscreen does not prevent or treat Raynaud's phenomenon, which is caused by cold or stress, not by sun exposure.
Choice C reason: "In order to avoid flareups of Raynaud's, ensure you wear gloves in winter." is a correct answer, because it can help prevent or reduce the symptoms of Raynaud's phenomenon. Wearing gloves in winter can keep the hands warm and prevent the blood vessels from narrowing and spasming due to cold. This can improve the blood flow and prevent color changes, numbness, pain, or ulcers in the fingers.
Choice D reason: "In order to avoid flareups of Raynaud's, ensure you brush your teeth for two minutes." is not a correct answer, because it is not related to Raynaud's phenomenon. Brushing the teeth for two minutes is a good oral hygiene practice that can prevent dental problems, such as plaque, cavities, or gingivitis. However, brushing the teeth does not affect the blood vessels in the fingers and toes, nor does it prevent or treat Raynaud's phenomenon.
Correct Answer is C
Explanation
Choice A reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system. CD4+ Tcells and CD8+ Tcells are types of white blood cells that play a key role in the immune response. CD4+ Tcells are helper cells that activate and coordinate other immune cells, while CD8+ Tcells are cytotoxic cells that kill infected or abnormal cells. Human immunodeficiency virus infects and destroys CD4+ Tcells, which impairs the immune function and increases the risk of opportunistic infections and cancers. CD8+ Tcells are not directly affected by the virus, but they may increase in number as a compensatory mechanism to fight the infection. Therefore, most adults with human immunodeficiency virus will have lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells.
Choice B reason: Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal may indicate a condition that affects both types of Tcells, such as aplastic anemia, chemotherapy, radiation therapy, or immunosuppressive drugs.
Choice C reason: Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells is a laboratory value that most adults with human immunodeficiency virus will exhibit, because it reflects the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells may indicate the progression of the infection and the severity of the immunodeficiency. The normal range of CD4+ Tcells is 500 to 1500 cells per microliter of blood, while the normal range of CD8+ Tcells is 150 to 1000 cells per microliter of blood.
Choice D reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low may indicate a condition that affects CD8+ Tcells, such as leukemia, lymphoma, or corticosteroid therapy.
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