96. What is the best nursing action to prevent pressure sores during a long surgical procedure?
. Pad bony prominences before surgery begins.
. Turn the client every 2 hours.
. Perform range of motion on the affected joints.
. Provide an alternating pressure mattress.
Test-Taking Tip
Choose the one option that is different than the others (before surgery). Three of the options will move the client during surgery, which is not feasible.
Content Area: Adult Health, Integumentary; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
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Answer 1 is correct because padding is very important before surgery begins. During surgery, the client will be immobilized on a hard surface. Answer 2 is incorrect because turning is an excellent preventative strategy in the unit, but not during the surgery. Answer 3 is incorrect because range of motion prevents contractures, not pressure sores. In addition, ROM is not done during surgery. Answer 4 is incorrect because an alternating pressure mattress makes the client's body move. This is not reasonable during surgery.