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NCLEX Question of the Day
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A nurse is caring for a patient who is at risk for developing pressure ulcers. Which of the following actions should the nurse take to minimize this risk?
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Keep the head of the bed elevated at 45 degrees at all times.
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Correct answer Reposition the patient at least every 2 hours while in bed.
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Massage over bony prominences to promote circulation.
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Use a donut-shaped cushion to relieve pressure on the sacral area.
Rationale
Repositioning the patient at least every 2 hours while in bed is a recommended practice to reduce pressure and shear forces that contribute to the development of pressure ulcers. Keeping the head of the bed elevated at 45 degrees can increase the risk of shear. Massaging over bony prominences is contraindicated as it can cause tissue damage. Donut-shaped cushions are not recommended as they can actually increase pressure on the tissues surrounding the opening.
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