ATI LPN EXAM
ATI LPN EXAM ( 47 Questions)
A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
Reposition the client every 4 hr:Repositioning is a crucial preventive measure for pressure injuries. However, the frequency should typically be more frequent, such as every 2 hours. This helps to relieve pressure on vulnerable areas and promotes circulation.
Elevate the head of the client's bed 45°:Elevating the head of the bed can reduce pressure on the sacral area, which is a common site for pressure injuries. However, this alone is not sufficient, and regular repositioning should still be implemented.
Massage the client's bony prominences:
Massaging bony prominences can cause friction and shear, potentially increasing the risk of skin breakdown. This action is generally not recommended.
Provide the client with a high-calorie diet:While proper nutrition is important for overall health, a high-calorie diet alone may not directly prevent pressure injuries. Adequate protein intake is particularly crucial for tissue repair and skin integrity.
A. Reposition the client every 4 hr:
Repositioning is a crucial preventive measure for pressure injuries. However, the frequency should typically be more frequent, such as every 2 hours. This helps to relieve pressure on vulnerable areas and promotes circulation.
B. Elevate the head of the client's bed 45°:
Elevating the head of the bed can reduce pressure on the sacral area, which is a common site for pressure injuries. However, this alone is not sufficient, and regular repositioning should still be implemented.
C. Massage the client's bony prominences:
Massaging bony prominences can cause friction and shear, potentially increasing the risk of skin breakdown. This action is generally not recommended.
D. Provide the client with a high-calorie diet:
While proper nutrition is important for overall health, a high-calorie diet alone may not directly prevent pressure injuries. Adequate protein intake is particularly crucial for tissue repair and skin integrity.