The supervising nurse watches a newly hired nurse take care of a client who is at risk of developing a pressure ulcer.
Which of the following interventions by the newly hired nurse requires follow-up?
Select all that apply.
The supervising nurse watches a newly hired nurse take care of a client who is at risk of developing a pressure ulcer.
Which of the following interventions by the newly hired nurse requires follow-up?
Select all that apply.
Statistics
Subject/Lesson
Subject
Adult Health
Lesson
Integumentary
Client Need
Test Plan
Basic Care and Comfort
Related Topic
Mobility/Immobility
Item Type
Item Type
Application
Explanation
Choice B is correct. If the newly hired nurse provides a donut pillow while the client sits in the chair, this will require follow-up because this pillow creates pressure and damages capillary beds. A donut pillow also reduces blood flow to the area. A regular pillow or foam type of device is recommended.
Choice C is correct. Maintaining the client's position at 90 degrees would require follow-up because this contributes to the client sliding, creating shearing. It is recommended that they be kept at 30 degrees (if not medically contraindicated).
Choice D is correct. A carbohydrate-rich diet is unhelpful to a client at risk for a pressure ulcer. A diet high in protein is recommended to maintain skin integrity and mitigate edema.
Choice A is incorrect. Applying zinc oxide to the client's skin is recommended. This product is a common ingredient in topical creams because it repels moisture.
Choice E is incorrect. Floating the client's heels is essential as it helps offload and evenly distribute pressure. This can be done using a device comprised of foam or a pillow.
Related Videos
4 Key Topics
Pressure Ulcer Risk Factors
25.3 Pressure Injury Risk & Development
Pressure Ulcer Staging
25.3 Pressure Injury Risk & Development
Additional Info
Recommended interventions for a client at risk of developing a pressure ulcer include the following:
✓ Utilize standardized assessments to evaluate a client’s risk for a pressure ulcer.
✓ Ensure that nutritional goals are being met by providing adequate fluid and protein in the diet.
✓ Keep the head of the bed at 30 degrees or less to prevent shearing.
✓ Offload bony prominences using foam or pillows. Reposition the client at least every two hours.
✓ Do not use any products comprised of plastic and avoid using donut pillows.
✓ Moisturize the skin with products containing zinc oxide.
✓ Do not massage reddened areas.
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