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. BUN (Blood Urea Nitrogen):
Explanation: BUN is a measure of kidney function and hydration status. It is not typically elevated in response to a localized infection like a pressure ulcer.

B. WBC count (White Blood Cell count):
Explanation: An elevation in the WBC count is a common indicator of infection. Increased white blood cells suggest the body's immune response to an infection.

C. Potassium:
Explanation: Potassium levels are not typically used to indicate the presence of infection. Elevated potassium may be seen in conditions affecting kidney function.

D. RBC count (Red Blood Cell count):
Explanation: The RBC count is not a specific marker for infection. It is more related to issues such as anemia or oxygen-carrying capacity.

A. Bradycardia B. Oliguria C. Peripheral edema D. Hypotension

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.

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

Correct Answer is B

Explanation

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

A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?

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?

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 is at risk for a pressure injury. Which of the following actions should the nurse take?

A nurse is assisting with teaching a class about minerals. Which of the following minerals is needed for transport of oxygen?

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?

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