CRNE Exam Prep

Category - Changes in Health

The nurse is caring for an older client confined to bed. To reduce the risk of a pressure ulcer, the most appropriate action of the nurse is to:
  1. Encourage the client to increase his intake of foods high in protein.
  2. Massage the bony prominences every 2 hours.
  3. Turn the client every 3 hours.
  4. Apply lotion in generous amounts to keep the skin from drying.
Explanation
Answer: A - Prevention of pressure ulcers is achieved through increased intake of foods high in protein to keep the skin healthy and to avoid skin breakdown. Inadequate protein intake encourages skin breakdown, impairing tissue healing. Massaging bony prominences and reddened areas increases the risk of skin breakdown. Turning is recommended at least once every 2 hours. Application of lotion can keep the skin moisturized; however, without proper nutrition, this intervention becomes ineffective.
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