Which activity should the nurse implement to decrease shearing force on a client's stage Il pressure injury?
pulling the client up from under the arms
improving the client's hydration
lubricating the area with skin cream
preventing the client from sliding in bed
The Correct Answer is D
A) Pulling the client up from under the arms: This action can increase shearing force on the client's skin, especially if done abruptly or without proper assistance. Pulling the client up by the arms can create friction and shear between the skin and underlying tissues, potentially worsening the pressure injury.
B) Improving the client's hydration: While hydration is essential for overall skin health, it is not directly related to reducing shearing force on a pressure injury. Hydration can help maintain skin integrity and promote healing but does not directly address the mechanical forces contributing to pressure injuries.
C) Lubricating the area with skin cream: While skin cream can help moisturize and protect the skin, it may not necessarily reduce shearing force on a pressure injury. While lubrication can reduce friction between surfaces, it may not be sufficient to prevent shearing forces that occur during movement or repositioning.
D) Preventing the client from sliding in bed: This is the most appropriate action to decrease shearing force on a stage II pressure injury. Sliding in bed can exacerbate shearing forces on the skin, leading to further damage or delayed healing of the pressure injury. Using devices such as pillows, positioning aids, or specialized mattresses can help prevent the client from sliding and minimize shearing forces on the affected area, promoting healing and preventing further injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Contact: While contact precautions are important for preventing the transmission of infections, they primarily apply to clients with known or suspected infections that can spread through direct or indirect contact with the client or their environment. Protective isolation goes beyond contact precautions and involves comprehensive measures to protect immunocompromised clients from all potential sources of infection.
B) Airborne: Airborne precautions are necessary for clients with infections that spread through the airborne route, such as tuberculosis or measles. While respiratory infections can pose a significant risk to immunocompromised clients, the focus of care for clients after hematopoietic stem-cell transplant is on preventing all types of infections, not just airborne ones.
C) Droplet: Droplet precautions are used for infections transmitted through respiratory droplets expelled when a person coughs, sneezes, or talks, such as influenza or pertussis. While respiratory infections are a concern for immunocompromised clients, the broader approach of protective isolation is more appropriate for clients after hematopoietic stem-cell transplant, as it encompasses all potential routes of infection transmission, not just droplet spread.
D) Protective: Clients who have undergone allogeneic hematopoietic stem-cell transplant are profoundly immunocompromised due to the destruction of their immune system and are highly susceptible to infections. Protective isolation, also known as reverse isolation, is necessary to minimize the risk of infection in these clients. This includes implementing strict infection control measures such as wearing gowns, gloves, masks, and sometimes goggles to prevent exposure to pathogens. Additionally, maintaining a clean environment and limiting visitors and healthcare personnel who may carry infectious agents are essential components of protective isolation.
Correct Answer is A
Explanation
A) Cheyne-Stokes respirations:
Cheyne-Stokes respirations are characterized by a cycle of gradually increasing and then decreasing respirations followed by a period of apnea. This pattern repeats in a regular cycle. It is commonly observed in clients with conditions affecting the central nervous system, such as traumatic brain injury, stroke, or brain tumors. Cheyne-Stokes respirations can also occur during the dying process. The alternating periods of hyperventilation and apnea result from fluctuations in oxygen and carbon dioxide levels in the blood.
B) Kussmaul respirations:
Kussmaul respirations are deep, rapid, and labored breathing patterns often observed in clients with metabolic acidosis, particularly diabetic ketoacidosis. Unlike Cheyne-Stokes respirations, Kussmaul respirations do not involve periods of apnea.
C) Apneustic respirations:
Apneustic respirations are characterized by prolonged inspiratory gasps followed by insufficient expiration. This irregular breathing pattern typically indicates damage to the pons, a part of the brainstem involved in regulating breathing. Apneustic respirations are different from the pattern described in the scenario.
D) Stridor:
Stridor is a high-pitched, noisy respiratory sound heard on inspiration that indicates upper airway obstruction, such as from swelling, foreign body aspiration, or tumors. It is not associated with the alternating pattern of hyperventilation and apnea described in Cheyne-Stokes respirations.
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