The RN identifies that a client is at risk for impaired skin integrity.
Which interventions should the nurse add to this client\u2019s plan of care?<\/p>\n\n\n\n
A.
Place the patient in a side-lying position only.<\/p>\n\n\n\n
B.
Massage bony prominences.<\/p>\n\n\n\n
C.
Use positioning devices such as foam wedges.<\/p>\n\n\n\n
D.
Keep the head of the bed elevated higher than 30 degrees. E. Inspect skin every shift.<\/p>\n\n\n\n
The Correct answer and Explanation is:<\/mark><\/strong><\/p>\n\n\n\n The correct answer is C. Use positioning devices such as foam wedges.<\/strong><\/p>\n\n\n\n Clients at risk for impaired skin integrity, such as those with limited mobility, malnutrition, or moisture exposure, require careful interventions to prevent pressure ulcers and skin breakdown. While all options may seem relevant, they differ in their effectiveness and appropriateness.<\/p>\n\n\n\n A. Place the patient in a side-lying position only.<\/strong> B. Massage bony prominences.<\/strong> C. Use positioning devices such as foam wedges.<\/strong> D. Keep the head of the bed elevated higher than 30 degrees.<\/strong> E. Inspect skin every shift.<\/strong> In summary, using positioning devices like foam wedges is a proactive and effective strategy to maintain skin integrity by reducing pressure on vulnerable areas, making it the most appropriate choice in this context.<\/p>\n","protected":false},"excerpt":{"rendered":" The RN identifies that a client is at risk for impaired skin integrity.Which interventions should the nurse add to this client\u2019s plan of care? A.Place the patient in a side-lying position only. B.Massage bony prominences. C.Use positioning devices such as foam wedges. D.Keep the head of the bed elevated higher than 30 degrees. E. Inspect […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-141593","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/141593","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=141593"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/141593\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=141593"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=141593"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=141593"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}Explanation<\/h3>\n\n\n\n
While side-lying positioning can help relieve pressure on certain bony prominences, relying solely on this position can lead to pressure on other areas, such as the hips and shoulders, increasing the risk of skin breakdown.<\/p>\n\n\n\n
Massaging bony prominences is contraindicated for clients at risk for skin integrity issues. Massage can increase blood flow, but it can also cause further tissue damage and lead to skin breakdown. Instead, caregivers should protect these areas.<\/p>\n\n\n\n
This is the best intervention because positioning devices help redistribute pressure away from bony prominences, reducing the risk of pressure ulcers. Foam wedges and similar devices can provide support, keep the patient properly aligned, and facilitate effective weight distribution.<\/p>\n\n\n\n
Elevating the head of the bed can lead to increased pressure on the sacrum and heels, which may elevate the risk of skin breakdown. It is often recommended to keep the head of the bed at 30 degrees or lower unless contraindicated.<\/p>\n\n\n\n
Regular skin inspection is indeed important for early detection of any changes or breakdowns; however, it is more of a monitoring strategy than an intervention. While it should be part of the care plan, it doesn\u2019t directly contribute to preventing skin integrity impairment.<\/p>\n\n\n\n