WALL STREET PREP GRADED A+
Which instruction from the nurse to an 80-year-old client with thinning of a
subcutaneous layer would be beneficial?
a. Dress warmly in cold weather.
b. Use soaps with high fat content.
c. Change the position of bed once every 5 hours. d. Apply moisturizer 2 hours
after bathing .
a
A client has a stage pressure injury. Which nursing intervention can prevent further
injury by eliminating shearing force?
a. Maintain the head of the bed at 30 degrees or less .
b. Use draw sheets to pull up, transfer , and position the client .
c. Reposition the client every 2 hours, propping with pillows.
d. Perform passive range -of-motion exercises every 8 hours.
b
In which area of the body will the nurse most likely discover a pressure injury in a
client who is maintained in the low-Fowler position excessively? a. Elbows
,b. Occiput
c. Hium
d. Sacrum
d
Which meal is most appropriate for a client with a large pressure injury?
a. Hamburger with french fries
b. Turkey meatloaf with brown rice
c. Pasta and tomato sauce with a side salad
d. Grilled chicken, steamed spinach, and a side of orange slices
d
Which intervention would be included in the plan of care for the prevention of a
pressure injury?
a. Positioning a client directly on the trochanter
b. Keeping the client's skin directly off plastic surfaces
c. Keeping the head of the bed elevated above 30 degrees
d. Placing a rubber ring or donut under the client's sacral area
, b
An older adult who is in acute care has a risk of skin breakdown. Which
interventions are beneficial to the client? (Select all that apply)
A. Providing meticulous skin care
B. Reducing shear forces and friction
C. Providing beverages and snacks frequently
D. Using a support surface base all the time
E. Avoiding pressure with proper positioning
a,b,e
Which combination of client responses would the nurse determine represents the
highest risk for the development of pressure injuries?
a. Incontinence; inability to move independently
b. Periodic diaphoresis; occasional sliding down in bed
c. Minimal reaction to painful stimuli; receiving tube feedings
d. Spending extensive time in a chairbody mass index (BMI) of 23
a