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 B

Explanation

A. Diarrhea:
Explanation: Vomiting is more likely to be associated with dehydration than diarrhea. While vomiting and diarrhea can both lead to fluid loss, dehydration is a more immediate concern.

B. Dehydration:
Explanation: This is correct. Vomiting can lead to a significant loss of fluids, and dehydration is a potential complication. It's important to monitor the client's fluid balance, provide oral rehydration solutions or intravenous fluids as needed, and address the underlying cause of vomiting.

C. Urinary frequency:
Explanation: While dehydration can lead to decreased urine output, urinary frequency is not a typical complication of vomiting. Dehydration often results in decreased urine production.

D. Peripheral edema:
Explanation: Peripheral edema is not a direct complication of vomiting. It is more commonly associated with conditions such as heart failure or renal issues.

A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen. B. Irrigate the wound with an antiseptic prior to obtaining the specimen. C. Include intact skin at the wound edges in the culture. D. Swab an area of skin away from the wound to identify normal flora.

Correct Answer is A

Explanation

A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
This is a correct action. Cleaning the wound with a sterile solution, such as 0.9% sodium chloride, helps minimize contamination and ensures a more accurate culture.

B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
Using antiseptics directly on the wound before obtaining a specimen can interfere with the culture results. It's essential to use a non-bacteriostatic solution for cleaning.

C. Include intact skin at the wound edges in the culture.
The culture should focus on the material within the wound itself rather than including intact skin. The goal is to identify the specific pathogens causing the infection.

D. Swab an area of skin away from the wound to identify normal flora.
The specimen should be taken directly from the wound site to identify the pathogens responsible for the infection. Swabbing away from the wound won't provide relevant information.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting?

Correct Answer is B

Explanation

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?

A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?

A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse tests the pH of the client's aspirate. Which of the following pH levels should the nurse identify as an indication of correct placement of the tube?

A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

The nurse suspects the 4-year-old client is having a recurrence of minimal change nephrotic syndrome (MCNS) Which signs or symptom would the nurse observe in the client?

A nurse is contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings?

A nurse is caring for a client who has gestational diabetes and reports feeling shaky, sweaty, and having blurred vision. The client's blood glucose level is 48 mg/dL. Which of the following foods should the nurse give to the client? (Select all that apply).

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?