Tissue Integrity
A nurse is caring for a client with a pressure ulcer on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize?
lean meats and low-fat milk
When educating unlicensed nursing personnel (UAP) about how to prevent the development of pressure ulcers, the nurse should emphasize that most tissue injuries related to shearing can be prevented by:
proper positioning and moving of the client.
Which is appropriate for the nurse to include in a plan for the prevention of pressure ulcers?
systematic skin assessment at least once per shift
A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
Inadequate protein intake
A client is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility?
Turning the client every 2 hours and providing a low-air-loss mattress
The nurse is assessing a group of older adults. Which client is at greatest risk for skin breakdown?
reduced sensation of pressure.
A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan?
Develop a written, individual turning schedule.
When providing a massage to a client, the nurse notes a 1-inch in diameter reddened area on the client's right buttock. What intervention should the nurse implement?
Position the client off of the right buttock.
