When changing the soiled linen on the bed of a client who is ...

[audie]

When changing the soiled linen on the bed of a client who is comatose, the nurse notices a red-dened, blanchable area approximately 2 cm in diameter on her left buttock. The nurse's initial skin breakdown intervention is to:
 
  1. Position the client on her right side
  2. Finish providing fresh, dry linen to the client's bed
  3. Include a 2-hour turning schedule in the client's care plan
  4. Measure the area in order to describe it in the nurses' notes

Question 2

Which of the following clients has the greatest risk for friction-induced skin breakdown?
 
  1. A client who is obese and is frequently incontinent of both urine and feces
  2. A client who insists she is comfortable only when positioned on her left side
  3. A client who is cognitively impaired and comforts herself by wringing her hands
  4. An immobile client who slides down in the recliner where he spends the morning hours

[okolip]

Answer to Question 1

ANS: 1
Pressure is the major cause in pressure ulcer formation, and changing the client's position to minimize the time spent in a particular position will be the best intervention to relieve the pres-sure. The remaining options are appropriate, but none has priority over proper positioning of the client.

Answer to Question 2

ANS: 3
A friction injury occurs in clients who are restless or in those who have uncontrollable movements or any repetitive skin-against-skin motion. The other options represent friction or moisture factors that contribute to skin breakdown.

[audie]

Thanks

[okolip]

Welcome