Practice Question
Pressure ulcers are defined as an injury to the skin and/or underlying tissue resulting from pressure or in combination with shear, usually over a bony prominence. As a nurse, what do you know you must do to prevent pressure ulcers? (Select all that apply.)
Answer Choices:
Correct Answer:
Turn immobile clients every 2 hours off bony prominences.
Rationale:
Turn immobile clients every 2 hours off bony prominences
🔷 Frequent repositioning reduces prolonged pressure on bony prominences, which is the primary cause of ischemia and tissue breakdown.
🔷 Turning every 2 hours restores capillary blood flow, preventing skin necrosis.
🔷 This is a standard evidence-based practice in pressure ulcer prevention.
Use lift or draw sheets to move clients in bed
🔷 Lift sheets reduce shear and friction forces that damage skin and underlying tissue.
🔷 Shear disrupts capillary circulation, accelerating pressure ulcer formation.
🔷 Proper handling techniques are crucial for clients with fragile or compromised skin integrity.
Ensure that your client maintains a healthy nutritional status
🔷 Adequate protein, vitamins (C, A, E), and zinc support collagen synthesis and wound healing.
🔷 Malnutrition increases skin fragility and delays tissue repair, heightening ulcer risk.
🔷 Hydration also maintains tissue elasticity and perfusion.
Apply pressure-relieving devices to vulnerable areas
🔷 Foam cushions, specialized mattresses, and heel protectors redistribute pressure and reduce skin breakdown.
🔷 These devices are especially important for high-risk immobile patients.
🔷 They complement repositioning to provide continuous pressure relief.
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This question is from Smith Chason College- NURS 146 Gero Final Exam which contains 93 questions.
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From Exam
Smith Chason College- NURS 146 Gero Final Exam
93 Questions
View Full Exam Start PracticingQuestion Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Adult Health
- Answer Choices: 5