ATI LPN EXAM
ATI LPN EXAM ( 47 Questions)
A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?
Provide the client with a diet high in protein: While adequate protein intake is important for overall health, it's not the most immediate intervention for preventing skin breakdown.
Massage bony prominences to promote circulation:Massaging bony prominences can cause friction and shear, potentially damaging the skin. This practice is generally not recommended as it may increase the risk of skin breakdown, especially in individuals at risk.
Repositioning the client every 2-3 hours is a key intervention to prevent pressure ulcers, which are a common and serious type of skin breakdown in older adults. By regularly shifting the client's weight and relieving pressure on bony prominences, the nurse can maintain adequate blood flow and skin integrity.
Apply cornstarch to keep the skin dry:Cornstarch, when applied to the skin, can create a moist environment that may contribute to skin issues. It is not typically recommended for maintaining skin integrity, especially in areas susceptible to breakdown.
The correct answer is:
c. Reposition the client every 3 hr.
Here's why the other options are not recommended:
- a. Provide the client with a diet high in protein: While adequate protein intake is important for overall health, it's not the most immediate intervention for preventing skin breakdown.
- b. Massage bony prominences to promote circulation: While massage can improve circulation, it can also irritate fragile skin and potentially increase the risk of breakdown.
- d. Apply cornstarch to keep the skin dry: Cornstarch can absorb moisture but can also cake and irritate the skin, worsening the risk of breakdown.
Repositioning the client every 2-3 hours is a key intervention to prevent pressure ulcers, which are a common and serious type of skin breakdown in older adults. By regularly shifting the client's weight and relieving pressure on bony prominences, the nurse can maintain adequate blood flow and skin integrity.
Therefore, option c is the most effective intervention for the nurse to use in this situation.