what nursing interventions increase the risk the pressure injuries

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. What nursing interventions increase the risk the pressure injuries?

A. Padding hard surfaces
B. Have client sit in wheelchair as much as possible
C. Place pillows between bony surfaces
D. Keep head of bed (HOB) at or less than 3

Correct answer: B

Rationale:

2. A client has cellulitis on his left arm. What statement by the client indicates understanding of symptom management?

A. "I can use tight bandages on my arm."?
B. "I should not apply heat to my arm."?
C. "I can use a warm, moist towel on my arm."?
D. "I should use a cold, dry source on my arm."?

Correct answer: C

Rationale:

3. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.