A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?

Identify the clients at greatest risk for development of pressure ulcers.

Turn and position each client every 2 hr.

Use a barrier cream when performing perineal care.

Supervise clients to ensure adequate nutritional intake.

Answer and Explanation

The Correct Answer is A

A. Identify the clients at greatest risk for the development of pressure ulcers.
This option emphasizes the importance of individualized care. By identifying clients at the highest risk for pressure ulcers, healthcare providers can tailor preventive measures to address specific risk factors such as immobility, nutritional deficits, and skin conditions.

B. Turn and position each client every 2 hr.
Regular turning and repositioning are crucial in preventing pressure ulcers, especially in individuals with limited mobility. This helps distribute pressure, reducing the risk of skin breakdown. However, this alone may not be sufficient if other risk factors are not addressed.

C. Use a barrier cream when performing perineal care.
Barrier creams can be helpful in protecting the skin from moisture and friction, especially in areas prone to pressure ulcers. While this is a good practice, it may not be the top priority compared to identifying those at the highest risk.

D. Supervise clients to ensure adequate nutritional intake.
Proper nutrition plays a vital role in maintaining skin integrity. Malnutrition can contribute to the development of pressure ulcers. Monitoring and ensuring adequate nutritional intake are important components of prevention but may not be the initial priority.

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Correct Answer is C

Explanation

A. Bradycardia:
Explanation: Bradycardia refers to a slow heart rate. In hypervolemia (fluid overload), the heart often compensates by increasing the heart rate rather than causing bradycardia.

B. Oliguria:
Explanation: Oliguria refers to decreased urine output. In hypervolemia, the increased fluid volume can lead to increased urine output rather than oliguria.

C. Peripheral Edema:
Explanation: Peripheral edema, or swelling in the extremities, is a common manifestation of hypervolemia. Excess fluid can accumulate in the tissues.

D. Hypotension:
Explanation: Hypertension, not hypotension, is more commonly associated with hypervolemia. The increased volume of fluid in the blood vessels can lead to elevated blood pressure.

A. Metoprolol 50 mg. PO daily. B. Maintain accurate intake and output records. C. Furosemide Lasix 40 mg push. D. Encourage fluid intake, more than 2000 mL/day.

Correct Answer is C

Explanation

A. Metoprolol 50 mg PO daily:
This is a beta-blocker that helps lower blood pressure and heart rate. While it may be part of managing heart failure, it is not the immediate priority in a client presenting with signs of fluid overload and congestion.

B. Maintain accurate intake and output records:
Monitoring intake and output is important in managing fluid balance.
However, in this situation, the priority is to address the existing fluid overload promptly.

C. Furosemide (Lasix) 40 mg push:
Furosemide is a loop diuretic that promotes the excretion of excess fluid. Administering it "push" implies a more rapid onset of action, making it suitable for addressing acute fluid overload.

D. Encourage fluid intake, more than 2000 mL/day:
In the context of fluid overload, encouraging additional fluid intake is contraindicated. The focus should be on removing excess fluid with diuretic therapy rather than promoting more intake.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

The health care provider has written the following orders for a client with bounding peripheral pulses, weight gain of 2 lb., pitting edema, and moist crackles bilaterally. Which order will the nurse complete first?

Correct Answer is C

Explanation

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