Question

The client has been on bed rest for the last 12 days and has consistently been placed in the Semi Fowler’s position. The nurse assesses the client for tissue breakdown escpecially on the

a) greater trochanter

b) ankles

c) occipital area

d) sacrum

2) additional teaching is indicated when a family member visiting a patient in Droplet Isolation says I must.

a) pinch the metal band on the mask around the bridge of my nose

b) put on new mask every time I visit my family member

c) fold the mask within itself before I throw it away

d) change my face whenever it gets wet

Answer 1

When a patient is consistently placed in semi-fowkler's position then the nurse should assess the client for tissue breakdown especially on d)sacrum.

Rationale - Sacral region among the others is more prone to tissue breakdown or stress ulcers as this area is in more contact with the bed and due to friction during sliding of the client, tissue breakdown or stress ulcers occurs.

2)Additional teaching is indicated when a family member visiting a patient in droplet isolation says i must a) pinch the metal band on the mask around the bridge of my nose.

Rationale - By pinching the metal band on the mask around the bridge of the nose,the mask remains tight and firm so that even when you talk to family members, it does not slips down the nose.This way we can stop the spread of droplets to some extent.

Other options like wearing a new mask everytime visting a family member is not required as long as the mask is neat and clean.

Fold the mask within itself before throwing away is correct but it is not indicated during the family member visit and the other option is we cannot change the face when it is wet instead changing the mask when it is wet with nasal secretions is correct.