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Question

Difficulty: EasyBasic Care and Comfort

A nurse is creating a plan of care for an older adult client who is on strict bed rest and is at high risk for skin breakdown. Which of the following actions are appropriate to promote basic care and comfort? Select all that apply.

  1. Reposition the client at least every 2 hours to relieve pressure on vulnerable areas.Answer
  2. Use pillows to float the client's heels completely off the mattress surface.Answer
  3. Apply a moisture barrier ointment to the perineal skin after cleansing episodes of incontinence.Answer
  4. D
    Delegate the comprehensive daily skin risk assessment to the unlicensed assistive personnel (UAP).
  5. E
    Maintain the head of the bed at a 90-degree angle continuously to reduce pressure on the sacrum.
  6. F
    Assume that the client's new, sudden onset of severe urinary incontinence is a normal part of the aging process.

Answer

The appropriate actions are repositioning the client at least every 2 hours, using pillows to float the heels, and applying a moisture barrier ointment to the perineal skin.
The correct interventions directly address the hazards of immobility by reducing prolonged pressure on bony prominences (through frequent repositioning and floating heels) and protecting the skin from moisture-associated damage (using barrier creams). These are standard, effective basic care measures.

Step-by-Step Solution

1
Identify the client's primary risks based on the scenario.
The client is an older adult on strict bed rest, making them highly vulnerable to pressure injuries, skin maceration, and complications of immobility.
Understanding the client's vulnerability is necessary to select effective basic care and comfort measures.
2
Evaluate each nursing intervention for safety, efficacy, and scope of practice.
Repositioning, floating heels, and applying moisture barriers are safe, evidence-based nursing interventions. Delegating assessments, using high Fowler's continuously, and ignoring acute symptoms are unsafe or inappropriate.
To ensure the selected interventions actively promote comfort and prevent harm while adhering to nursing standards.

Key Concept

Basic Care and Comfort for Immobile Older Adults
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Topics

Basic Care and Comfort

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