What nursing interventions increase the risk the pressure injuries?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Have client sit in a wheelchair as much as possible. This option increases the risk of pressure injuries because prolonged sitting can lead to pressure points on bony prominences, especially if the individual is unable to shift their weight or change positions frequently. This can result in decreased blood flow to the area, leading to tissue damage and the development of pressure injuries. Option A) Padding hard surfaces is actually a preventive measure that reduces the risk of pressure injuries by providing cushioning and reducing pressure on bony areas. Option C) Placing pillows between bony surfaces is also a recommended nursing intervention to prevent pressure injuries by reducing pressure and friction on vulnerable areas. Option D) Keeping the head of the bed at or less than 30 degrees is a measure to prevent aspiration in patients at risk of choking or aspiration pneumonia, and it is not directly related to the development of pressure injuries. Educationally, understanding the risk factors and preventive measures for pressure injuries is crucial for nurses caring for patients with limited mobility. It is essential to promote frequent repositioning, proper support surfaces, and pressure-relieving devices to mitigate the risk of pressure injuries and provide optimal care for patients at risk.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Blurred vision. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) commonly used to treat rheumatoid arthritis. One of the potential adverse effects of NSAIDs, including ibuprofen, is visual disturbances such as blurred vision. Option A) Bleeding is incorrect because while NSAIDs can increase the risk of bleeding in some cases, blurred vision is a more specific adverse effect associated with ibuprofen use in this context. Option B) Insomnia and Option D) Constipation are unlikely adverse effects of ibuprofen. Insomnia is not a common side effect of NSAIDs like ibuprofen, and constipation is more commonly associated with other types of medications or health conditions. Educationally, it is important for nurses to understand the potential adverse effects of medications they administer to ensure patient safety and optimal outcomes. Teaching patients about common side effects empowers them to monitor their own health and seek appropriate medical attention if needed. It also highlights the critical role of patient education in promoting medication adherence and preventing complications.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Massaging the client's reddened shoulders and heels. Massaging or rubbing reddened areas can increase the risk of pressure injuries by causing friction and shearing forces on the skin, especially in individuals with compromised skin integrity. Option A, applying moisturizer to dry areas of the skin, is aimed at maintaining skin hydration and integrity, which can actually help prevent pressure injuries. Option C, cleansing the skin routinely after soiling occurs, is also a good practice to prevent skin breakdown. Option D, using a Hoyer lift for all transfers, is important for safe patient handling and does not directly increase the risk of pressure injuries. In an educational context, it is crucial for healthcare providers to understand the principles of pressure injury prevention. This includes avoiding actions that can damage fragile skin and implementing strategies to reduce pressure, friction, and shear on vulnerable areas of the body. Educating caregivers on proper skin care and transfer techniques is essential to ensure the well-being of bedridden patients.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Blanching. When the nurse presses down on the erythematous area and it turns white, this indicates that the blood flow to the area has temporarily stopped, causing blanching. This test helps assess the vascular response of the skin. Option A) Non-blanching is incorrect because blanching specifically refers to the skin turning white upon pressure, which is the opposite of non-blanching. Option C) Redness is incorrect as it describes the initial color of the area, not the change that occurs with pressure. Option D) Warmth is incorrect as it does not describe the visual change seen with pressure. Educationally, understanding blanching is crucial for healthcare providers as it aids in assessing skin perfusion, circulation, and potential issues like inflammation or infection. Recognizing blanching helps nurses and medical professionals make informed decisions about patient care and intervention strategies.

Correct Answer: A

Rationale: In the context of multi-dimensional care, understanding a client's primary defense mechanisms against infection is crucial for healthcare professionals. The correct answer, A) Intact skin, is a fundamental barrier that prevents pathogens from entering the body. Intact skin acts as the first line of defense by physically blocking the entry of microorganisms, thereby reducing the risk of infection. Option B) Inflammation is a secondary response to infection, characterized by redness, swelling, and pain. While inflammation is part of the body's immune response, it is not the primary defense mechanism against infection. Option C) Phagocytosis is a process where immune cells engulf and destroy pathogens. Although phagocytosis plays a vital role in fighting infections, it is not the client's primary defense mechanism. Option D) Fever is a systemic response to infection that helps the body fight off pathogens by creating an inhospitable environment for them. However, fever is a secondary defense mechanism and not the primary one. Educationally, this question highlights the importance of recognizing the body's natural defense mechanisms in preventing infections. By understanding the hierarchy of defense mechanisms, healthcare providers can better assess, treat, and educate clients on infection prevention strategies. Knowledge of primary defenses like intact skin empowers healthcare professionals to promote holistic care and support optimal health outcomes for clients.