When planning care for a client at risk for developing pressure ...

[Caiter2013]

When planning care for a client at risk for developing pressure ulcers, which intervention should be included? Select all that apply.
 
  A) Initiate a frequent toileting schedule.
  B) Raise the heels off of the bed.
  C) Turn the client every 4 hours.
  D) Use inflatable doughnut-style devices to reduce pressure on the sacrum.
  E) Massage pressure areas with lotion every 4 hours.

Question 2

The nurse is concerned that a client is at risk for pressure ulcers. Which assessment data supports the nurse's concern? Select all that apply.
 
  A) Age 54
  B) Body temperature within normal limits
  C) Low serum albumin level
  D) Continence of urine and stool
  E) Prescribed bedrest

[Kingjoffery]

Answer to Question 1

Answer: A, B

Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and potential for skin breakdown. Raising the heels off of the bed should be done to remove pressure from this area of the client's body. The client should be turned at least every 2 hours. Massage of pressure areas can cause friction and damage to problem skin areas. Inflatable doughnut-style devices are contraindicated, as they increase pressure and reduce perfusion to affected areas.

Answer to Question 2

Answer: C, E

Risk factors for pressure ulcer development include immobility and inadequate nutrition. The client who is prescribed bedrest is at risk for immobility, and a low serum albumin level is evidence of inadequate nutrition. Continence of urine and stool would reduce the risk of pressure ulcer development. The age of 54 would not increase the client's risk for pressure ulcer development. A normal body temperature would reduce the client's risk for pressure ulcer development.

[Caiter2013]

TYSM

[helenmarkerine]

Excellent