Examkin

Question

Difficulty: EasyBasic Care and Comfort

A client is restricted to strict bed rest following a prolonged surgical procedure. Which interventions should the nurse implement to promote physical comfort and prevent tissue breakdown? Select all that apply.

  1. Turn and reposition the client at least every two hours.Answer
  2. B
    Maintain the client in a continuous high Fowler's position to reduce sacral shear.
  3. Keep the bottom bed linens clean, dry, and free of wrinkles.Answer
  4. D
    Assign the unlicensed assistive personnel (UAP) to perform the daily pressure ulcer risk assessment.
  5. Apply a moisture barrier cream to the perineal skin after incontinent episodes.Answer
  6. F
    Apply soft wrist restraints to prevent the client from scratching dry, itchy skin.

Answer

The correct interventions are to turn and reposition the client at least every two hours, keep the bottom bed linens clean, dry, and free of wrinkles, and apply a moisture barrier cream to the perineal skin after incontinent episodes.
Promoting basic care and comfort for an immobile client requires proactive measures against pressure, friction, and moisture. Turning the client at least every two hours redistributes body weight and restores capillary blood flow to vulnerable areas. Keeping the bed linens dry and wrinkle-free eliminates physical friction that can abrade the epidermis. Finally, applying a moisture barrier protects the skin from maceration caused by exposure to incontinence.

Step-by-Step Solution

1
Identify the client's core risks.
The client is on strict bed rest, placing them at high risk for pressure injuries, skin breakdown, and general discomfort.
Recognizing mobility limitations is the first step in formulating a targeted basic care and comfort plan.
2
Select appropriate evidence-based comfort and skin integrity interventions.
Identified turning every two hours, smoothing linens, and applying moisture barriers as effective, foundational nursing actions.
These interventions directly mitigate pressure, friction, and moisture, which are the primary causes of skin breakdown.
3
Rule out contraindicated actions and improper delegations.
Eliminated high Fowler's positioning (increases shear), delegating assessments to UAPs (outside scope of practice), and using restraints for itching (violates least-restrictive-first principle).
Ensures the care plan strictly adheres to safety standards, legal scope of practice, and standard precautions.

Key Concept

Foundational interventions for maintaining skin integrity and promoting physical comfort in immobile clients.
Estimated Time:1m 0s
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Topics

Basic Care and Comfort

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