Fundamentals PrepU Chapter 31: Skin Integrity and Wound Care

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? -Do not attempt to remove the sutures because they need more time to heal. -Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. -Pick the crusts off the sutures with the forceps before removing them. -Wash the sutures with warm, sterile water and an antimicrobial soap before removing them.

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

A client has a fissure on her finger due to chafing. The client asks "How long will it be painful?" The nurse explains that the inflammation phase will last: -3 days. -7 days. -2 weeks. -5 days.

3 days

The nurse would recognize which client as being particularly susceptible to impaired wound healing? -An obese woman with a history of type 1 diabetes -A client who is n.p.o. (nothing by mouth) following bowel surgery -A man with a sedentary lifestyle and a long history of cigarette smoking -A client whose breast reconstruction surgery required numerous incisions

An obese woman with a history of type 1 diabetes

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? -Enzymatic debridement -Biosurgical debridement -Autolytic debridement -Mechanical debridement

Biosurgical debridement

When performing a dressing change, the home care nurse notes that the base of the client's leg wound is red and bleeds easily. What is the appropriate action by the nurse? -Send the client to the emergency room. -Notify the physician. -Document the findings. -Consult a wound care nurse.

Document the findings.

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action? -Exert equal, but not excessive, tension with each turn of the bandage. -Elevate and support the stump. -Keep bandage free from gaps between each turn. -Wrap distally to proximally.

Elevate and support the stump.

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood? -Duoderm -OpSite -Gauze -Tegasorb

Gauze

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by: -primary intention. -secondary intention. -tertiary intention. -dehiscence.

Primary Intention

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room? -Montgomery straps -DuoDerm -Tegaderm -Gauze

Tegaderm

True or False: A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

True

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury? -a newborn -an older client with arthritis -a critical care client -a client with cardiovascular disease

a critical care client

A client's risk for the development of a pressure injury is most likely due to which lab result? -glucose 110 mg/dL -albumin 2.5 mg/dL -hemoglobin A1C 7% -sodium 135 mEq/L

albumin 2.5 mg/dL

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: -to provide drainage for bile. -to divert drainage to the peritoneal cavity. -to decrease dead space by decreasing drainage. -to provide a sinus tract for drainage.

to provide drainage for bile.

The nurse and client are looking at a client's heel pressure injury. The client states, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? -"Necrotic tissue is devitalized tissue that must be removed to promote healing." -"You are seeing undermining, a type of tissue erosion." -"This is normal tissue." -"That is called slough, and it will usually fall off."

"Necrotic tissue is devitalized tissue that must be removed to promote healing."

The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching? -"After delivery, I will have sutures in place." -"Steri-Strips will hold my wound together until it heals." -"I may have staples in place for a number of days." -"I will not remove the staples myself."

"Steri-Strips will hold my wound together until it heals."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? -"If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." -"Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." -"As soon as the infection clears, your surgeon will staple the wound closed." -"Your wound will heal slowly as granulation tissue forms and fills the wound."

"Your wound will heal slowly as granulation tissue forms and fills the wound."

The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? -Assess the client for claustrophobia. -Assess the wound for active bleeding. -Assess for the use of antihypertensives. -Assess the client's mental status.

Assess the wound for active bleeding.

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? -Yellow classification -Black classification -Red classification -Unstageable

Black Classification

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? -contusion -avulsion -incision -puncture

Contusion

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? -Change the dressing. -Notify the wound care nurse. -Document the findings. -Contact the health care provider.

Document the findings

The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care? -Apply an ice pack to relieve pain. -Cleanse labia with scented soap. -Expose the area to a heat lamp. -Soak in a warm bath for drainage.

Soak in a warm bath for drainage.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? -The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. -The nurse packs the wound cavity tightly with dressing material. -The nurse uses wet-to-dry dressings continuously. -The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown.

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

A nurse is assessing wound drainage during the immediate postoperative period for a client who has had a gall bladder removed. In addition to assessing the dressing, where should the nurse check for drainage? -in the axilla -under the skin -under the client -on the output sheet

under the client

A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention? -Contact the surgeon. -Apply sterile dressings with normal saline over the protruding organs and tissue. -Monitor for pallor and mottle appearance of the wound. -Assess for impaired blood flow to the area of evisceration.

Apply sterile dressings with normal saline over the protruding organs and tissue.

The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority? -Acute pain -Impaired tissue integrity -Knowledge deficit -Disturbed body image

Impaired tissue integrity

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? -abrasion -laceration -incision -avulsion

Incision

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? -Keep the swab and the inside of the culture tube sterile. -Utilize the culture swab to obtain cultures from multiple sites. -Stroke the culture swab on surrounding skin first. -Cleanse the wound after obtaining the wound culture.

Keep the swab and inside of the culture tube sterile

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? -Cutting with a sharp instrument with wound edges in close approximation with correct alignment -Puncture of the skin -Tearing of the skin and tissue with some type of instrument; tissue not aligned -Tearing of a structure from its normal position

Tearing of a structure from its normal position

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess? -The wound is 3 cm × 5 cm with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. -The wound is 3 cm × 5 cm with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing. -The wound is 3 cm × 5 cm with yellow tissue covering the entire wound. -The wound is a 3 cm × 5 cm blood-filled blister.

The wound is 3 cm × 5 cm with yellow tissue covering the entire wound.

While walking in the woods, an 8-year-old boy trips and a stick cuts his right leg. The camp nurse inspects the wound and determines a portion of the dermis is intact, so the nurse cleanses and bandages the wound. What wound classification will the nurse document on the child's health record? -Intentional, full-thickness wound -Intentional, partial-thickness wound -Unintentional, full-thickness wound -Unintentional, partial-thickness wound

Unintentional, partial-thickness wound

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? -a client sitting in a chair who slides down -a client who must remain on his back for long periods of time -a client who lifts himself up on his elbows -a client who lies on wrinkled sheets

a client sitting in a chair who slides down

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? -avulsion -incision -abrasion -laceration

incision

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? -Do not attempt to remove the sutures because they need more time to heal. -Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. -Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. -Pick the crusts off the sutures with the forceps before removing them.

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? -Secondary intention -Tertiary intention -Desiccation -Primary intention

Secondary Intention

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? -"Do you experience incontinence?" -"How many meals a day do you eat?" -"Have you had any recent illnesses?" -"Do you use any lotions on your skin?"

"Do you experience incontinence?"

The nurse is caring for a client with a knee sprain. Which client statement regarding use of an ice pack indicates that nursing teaching has been effective? -"I will put a washcloth between my knee and the ice pack." -"I will put this on my knee until it becomes numb." -"I can keep this on my knee for 45 minutes at a time." -"I must wait 5 minutes between cold therapy applications."

"I will put a washcloth between my knee and the ice pack."

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? -"The bulb-like system will stay in place permanently after your mastectomy." -"You will receive medication through this device." -"This drain minimizes the chance for bacteria to enter the surgical site." -"It provides a way to remove drainage and blood from the surgical wound."

"It provides a way to remove drainage and blood from the surgical wound."

The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include? -"Very little scar tissue will form." -"The surgeon will leave your wound intentionally open for a period of time." -"This is a complex reparative process." -"The margins of your wound are not in direct contact."

"Very little scar tissue will form."

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? -A wound healing naturally that becomes infected. -A surgical incision with sutured approximated edges -A wound left open for several days to allow edema to subside -A large wound with considerable tissue loss allowed to heal naturally

A surgical incision with sutured approximated edges

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? -"I must wait 15 minutes between applications of cold therapy." -"I will put a layer of cloth between my skin and the ice pack." -"I can let this stay on my ankle an hour at a time." -"I should keep this on my ankle until it is numb."

"I will put a layer of cloth between my skin and the ice pack."

Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply. -The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. -The nurse places a heating pad on a sprained wrist that is in the acute stage. -The nurse applies moist cold to a client's eye for 40 minutes every 2 hours. -The nurse instructs the client to lean or lie directly on the heating device. -The nurse makes more frequent checks of the skin of an older adult using a heating pad. -The nurse fills an ice bag with small pieces of ice to about two-thirds full.

-The nurse makes more frequent checks of the skin of an older adult using a heating pad. -The nurse fills an ice bag with small pieces of ice to about two-thirds full. -The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm.

A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply. -Elevate the head of the bed 90 degrees four times daily. -Encourage client to take fluids every 2 hours. -Provide incontinent care every 2 hours and as needed. -Pull client up in bed as needed. -Turn client every 2 hours while client in bed.

-Provide incontinent care every 2 hours and as needed. -Turn client every 2 hours while client in bed. -Encourage client to take fluids every 2 hours.

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for: -evisceration. -infection. -dehiscence. -herniation.

Dehiscence

The nurse has collected blood from a client for laboratory analysis. Which dressing supply will the nurse select to cover the site from which the blood was drawn? -OpSite -Gauze -Tegasorb -Montgomery strap

Gauze

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? -Using sterile technique, debride the wound. -Contact the surgeon for debridement. -Place an antiembolism stocking on the client's leg. -Off-load pressure from the heel.

Off-load pressure from the heel.

The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order. Proliferation Hemostasis Maturation Inflammatory

1. Hemostasis 2. Inflammatory 3. Proliferation 4. Maturation

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? -spica turn -circular turn -figure-of-eight turn -spiral-reverse turn

figure-of-eight turn

Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select? -Telfa -Negative wound pressure therapy -Hydrocolloid -Wet to dry

Hydrocolloid

A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound? -Stage II -Stage IV -Stage I -Stage III

Stage III

A nurse is caring for a client with a nonhealing stage IV pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition? -Eschar -Dehiscence -Undermining -Slough

Undermining

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? -hydrogels -alginates -transparent films -hydrocolloid dressings

hydrocolloid dressings

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate? -"Dehiscence is when a wound has partial or total separation of the wound layers." -"Dehiscence is a total separation of the wound with protrusion of the viscera through it." -"Dehiscence is the softening of tissue due to excessive moisture." -"Dehiscence is not anything that you need to worry about."

"Dehiscence is when a wound has partial or total separation of the wound layers."

A client has undergone an open surgical procedure. Which teaching provided by the nurse accurately reflects what the client should expect during the remodeling period? -"Neurophils and monocytes will migrate to the site of your incision." -"The wound will contract and scarring will shrink." -"Granulation tissue will start to form." -"Blood vessels will constrict to control blood loss."

"The wound will contract and scarring will shrink."

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. -a client with a peripheral vascular disorder -an older adult who is confined to bed -a client who is taking corticosteroid drugs -a 10-year-old client with a surgical incision -a client who is obese -a client who eats a diet high in vitamins A and C

-an older adult who is confined to bed -a client with a peripheral vascular disorder -a client who is obese -a client who is taking corticosteroid drugs

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains? -A Penrose drain promotes drainage passively into a dressing. -A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. -A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. -A Penrose drain is a closed drainage system that is connected to an electronic suction device.

A Penrose drain promotes drainage passively into a dressing.

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? -Use clean technique to clean the wound. -Clean the wound from the bottom to the top, and outside to center. -Clean the wound from the top to the bottom, and center to outside. -Once the wound is cleaned, dry the area with an absorbent cloth.

Clean the wound from the top to the bottom, and center to outside.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care? -Cleanse with a new gauze for each stroke. -Cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing. -Cleanse the wound from the outer area towards the inner area. -Cleanse the wound using parallel stroke from the top to the bottom of the wound.

Cleanse with a new gauze for each stroke.

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? -puncture -incision -contusion -avulsion

Contusion

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? -Antihypertensive drugs -Potassium supplements -Laxatives -Corticosteroids

Corticosteroids

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? -Dehiscence of the wound -Herniation of the wound -Infection of the wound -Evisceration of the viscera

Dehiscence of the wound

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? -Size -Tunneling -Depth -Direction

Depth

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? -Maceration -Evisceration -Necrosis -Desiccation

Desiccation

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client? -Autolytic debridement -Biosurgical debridement -Mechanical debridement -Enzymatic debridement

Mechanical debridement

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care the nurse notes the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize with this client's wound? -Inflammatory Phase -Maturation Phase -Hemostasis -Proliferation Phase

Proliferation Phase

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? -Assure that the packing material is completely saturated when placed in the wound. -Use less packing material. -Reduce the time interval between dressing changes. -Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.

Reduce the time interval between dressing changes.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document? -Serosanguineous -Serous -Sanguineous -Purulent

Serosanguineous

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? -necrosis of tissue -shearing force -friction -ischemia

Shearing Force`

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? -Stage III -Stage II -Stage IV -Stage I

Stage II

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury? -Stage IV -Stage I -Stage II -Stage III

Stage IV

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client? -Muscle layer -Dermis -Epidermis -Subcutaneous tissue

Subcutaneous tissue

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? -Keeps the wound clean -Maintains a moist environment -Supports the area around the wound -Reduces swelling and inflammation

Supports the area around the wound

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? -Tearing of a structure from its normal position -Puncture of the skin -Cutting with a sharp instrument with wound edges in close approximation with correct alignment -Tearing of the skin and tissue with some type of instrument; tissue not aligned

Tearing of a structure from its normal position

The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day? -The nurse compresses the container while the port is open, then closes the port after the device is compressed to empty the system before shortening the drain. -The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. -The nurse empties and suctions the device, following the manufacturer's directions prior to shortening the drain. -The nurse carefully cleans around the sutures with a swab and normal sterile saline solution prior to shortening the drain.

The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? -The nurse uses friction when cleaning the wound to loosen dead cells. -The nurse swabs the wound with povidone-iodine to fight infection in the wound. -The nurse swabs the wound from the bottom to the top. -The nurse works outward from the wound in lines parallel to it.

The nurse works outward from the wound in lines parallel to it.

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with: -a rash related to immobility. -an allergic reaction to detergent. -a rash related to a yeast infection. -an allergic reaction to medications.

a rash related to a yeast infection.

What is the best nursing diagnosis to describe a minor laceration to finger sustained when a client was cutting fruit in the kitchen with a knife? -knowledge deficit regarding wound care related to laceration -risk for infection related to wound -impaired skin integrity related to open wound -pain related to wound sustained by knife

impaired skin integrity related to open wound

A client has a fissure on her finger due to chafing. The client asks "How long will it be painful?" The nurse explains that the inflammation phase will last: -5 days. -7 days. -3 days. -2 weeks.

3 days

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? -Pasta salad -Banana -Green beans -Fish

Fish

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? -Place a foot board on the bed. -Provide incontinent care every 4 hours as needed. -Elevate the head of the bed 90 degrees. -Use pillows to maintain a side-lying position as needed.

Use pillows to maintain a side-lying position as needed.