While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

Avoid friction when sliding up in bed.

Offer supplemental nutritional snacks.

Change bed pads to keep skin clean and dry.

Change position frequently from right to left.

Answer and Explanation

The Correct Answer is D

A.   While avoiding friction can help to prevent skin breakdown, it's not the most important intervention for this client. Frequent position changes are more effective in reducing pressure on the skin and preventing ulcers.
B.   Nutrition is important for overall health, but it's not the most immediate concern in this case. Preventing pressure ulcers is the priority.
C.   While keeping the skin clean and dry is important, it's not the most effective way to prevent pressure ulcers. Frequent position changes are more important for reducing pressure on the skin.
D.   The most effective way to prevent pressure ulcers in immobile clients is to change their position frequently. This helps to relieve pressure on bony areas and promote circulation to the skin. By changing the client's position regularly, the nurse can help to reduce the risk of skin breakdown and the development of pressure ulcers.

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Correct Answer is B

Explanation

A. Orthopnea is a condition where a person has difficulty breathing when lying flat and may require sitting or standing to breathe more easily. While documenting orthopnea is important for the medical record and understanding the client’s condition, it is not the immediate priority in addressing acute breathing difficulty.
B. Elevating the head of the bed is an immediate and effective action to help alleviate breathing difficulty. This position helps improve respiratory mechanics by allowing the diaphragm to move more freely and reducing pressure on the lungs.
C. Using a pulse oximeter to measure oxygen saturation is important for assessing the client’s oxygen levels and determining the need for supplemental oxygen. However, this action is secondary to immediately addressing the position that is causing difficulty.
D. Assessing vital signs is important for a comprehensive evaluation of the client’s overall condition and to identify any critical changes in health status. However, in the case of immediate breathing difficulty, it is more urgent to take actions that directly address the breathing issue before performing a thorough assessment.

A. Cover moist areas of the skin with cornstarch. B. Gently apply lotion to the skin after bathing. C. Add bath oil directly to the warm bath water. D. Switch to using a liquid soap for bar soap.

Correct Answer is B

Explanation

A. Applying cornstarch or other powders to moist skin can exacerbate dryness and irritation, as powders can absorb moisture but also contribute to a dry skin environment. In general, powders are not recommended for use on already dry or irritated skin, especially for older adults, as they can lead to further skin issues or contribute to fungal infections.
B. Gently applying lotion or moisturizer to the skin after bathing is the most appropriate action. Moisturizers help to rehydrate and lock in moisture, reducing the risk of dry, itchy skin. Applying lotion to damp skin (immediately after bathing) is particularly effective as it helps to seal in the moisture.
C. Adding bath oil to the bath water can be beneficial for moisturizing the skin, as it helps to create a barrier that prevents moisture loss. However, for the client’s specific request about post-bath relief, adding oil to the bath water does not address the immediate need for skin care after bathing.
D. Liquid soap can be gentler on the skin compared to bar soap, which can be drying, especially if it contains harsh ingredients. However, switching from bar soap to liquid soap is a preventive measure and does not provide immediate relief for already dry and itchy skin.

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While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

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Naxlex Comprehensive Predictor Exams

A client is having trouble breathing while lying in a dorsal recumbent position. Which action should the nurse implement first?

Correct Answer is B

Explanation

The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?

Correct Answer is B

Explanation

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While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

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