Examkin

Question

Difficulty: EasyBasic Care and Comfort

A practical nurse is providing basic care for a client who is on prolonged bed rest following an abdominal surgery. Which nursing actions will best promote client comfort and maintain skin integrity? Select all that apply.

  1. Keep the bottom bed sheets tight and free of wrinkles.Answer
  2. Reposition the client from side to side at least every two hours.Answer
  3. C
    Raise the knee gatch of the bed to prevent the client from sliding downward.
  4. Place a pillow under the client's lower legs to suspend the heels off the mattress.Answer
  5. E
    Maintain the client in a continuous flat, supine position to rest the spine.

Answer

The correct actions are keeping bed sheets tight and wrinkle-free, repositioning every two hours, and placing a pillow under the lower legs to suspend the heels.
Promoting client comfort and skin integrity involves minimizing pressure, friction, and shearing forces. Keeping bed linens tight and wrinkle-free eliminates physical irritants that can damage fragile skin. Turning and repositioning the client at least every two hours ensures that blood flow is restored to tissues overlying bony prominences. Placing a pillow under the calves effectively floats the heels, completely removing pressure from this highly vulnerable area.

Step-by-Step Solution

1
Identify the goal of care based on the stem.
The goal is to promote comfort and maintain skin integrity for a bedbound postoperative client.
Understanding the primary objective helps filter out actions that might cause harm or are ineffective.
2
Evaluate each option against basic care principles for skin integrity and safety.
Wrinkle-free sheets, frequent turning, and heel suspension are established, safe methods for preventing pressure injuries.
Evidence-based practice dictates these standard interventions for immobile clients.
3
Identify contraindicated positioning techniques.
Raising the knee gatch and keeping the client completely flat are identified as harmful practices.
These positions compromise circulation and respiratory function, violating basic safety and comfort principles.

Key Concept

Basic Care and Comfort: Skin Integrity and Positioning
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Topics

Basic Care and Comfort

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