Nokea
A nurse is planning care for a client with a sacral pressure ulcer. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Place a small pillow between bony surfaces.
- B. Elevate the head of the bed to 45 degrees.
- C. Limit fluids and proteins in the diet.
- D. Use a lift sheet to assist with re-positioning.
- E. Re-position the client who is in a chair every 2 hours.
- F. Keep the clients heels off the bed surfaces.
- G. Use a rubber ring to decrease sacral pressure when up in the chair.
Correct Answer: A,D,F
Rationale: A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and keeping heels off the bed reduces pressure on high-risk areas. Limiting fluids and proteins is not appropriate as they are essential for tissue integrity. Clients should be repositioned every hour while in a chair, not every 2 hours. A rubber ring impairs capillary blood flow, increasing pressure sore risk.
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After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the clients understanding. Which dietary choice by the client indicates a good understanding of the teaching?
- A. Low-fat diet with whole grains and cereals and vitamin supplements
- B. High-protein diet with vitamins and mineral supplements
- C. Vegetarian diet with nutritional supplements and fish oil capsules
- D. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet
Correct Answer: B
Rationale: The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein.
A nurse teaches a client who has very dry skin. Which statement should the nurse include in this clients education?
- A. Use lots of moisturizer several times a day to minimize dryness.
- B. Take a cold shower instead of soaking in the bathtub.
- C. Use antimicrobial soap to avoid infection of cracked skin.
- D. After you bathe, put lotion on before your skin is totally dry.
Correct Answer: D
Rationale: The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisturizer in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what dehydrates the skin, it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection?
- A. Client with blood cultures pending
- B. Client who has thin, serous wound drainage
- C. Client with a white blood cell count of 23,000/mm^3
- D. Client transferred from intensive care with an elevated white blood cell count
Correct Answer: C
Rationale: An elevated white blood cell count, such as 23,000/mm^3, indicates a potential infection. The nurse should evaluate this client for signs of a wound infection, as an elevated white blood cell count is a strong indicator of an infectious process.
A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.)
- A. Use a lift sheet when moving the client in bed.
- B. Avoid tape when applying dressings.
- C. Avoid whirlpool therapy.
- D. Use loose dressing on all wounds.
- E. Implement pressure-relieving devices.
Correct Answer: A,B,E
Rationale: Using a lift sheet prevents shearing forces, avoiding tape protects fragile skin, and pressure-relieving devices reduce pressure ulcer risk. Whirlpool therapy is not contraindicated, and dressings should be applied as prescribed, not necessarily loose.
A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer. Which diagnostic test should the nurse anticipate being ordered for this client?
- A. Punch skin biopsy
- B. Viral cultures
- C. Wood's lamp examination
- D. Diascopy
Correct Answer: A
Rationale: This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Wood's lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates polymorph making skin lesions easier to examine.