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. Fluid volume overload:
Explanation: Fluid volume overload is not typically associated with urinary incontinence. It is more commonly linked to conditions affecting the heart and kidneys.

B. Kidney stones:
Explanation: Kidney stones are not directly related to urinary incontinence. Kidney stones may cause pain, hematuria (blood in urine), and changes in urinary frequency.

C. Dermatitis:
Explanation: This is correct. Urinary incontinence can lead to skin irritation and dermatitis, especially if the skin is constantly exposed to urine. Keeping the perineal area clean and dry is important to prevent dermatitis.

D. Hypoglycemia:
Explanation: Hypoglycemia is not typically associated with urinary incontinence. It is more related to low blood sugar levels and is not a direct consequence of urinary incontinence.

A. Provide the client with a diet high in protein. B. Massage bony prominences to promote circulation. C. Reposition the client every 3 hr. D. Apply cornstarch to keep the skin dry.

Correct Answer is A

Explanation

A.Adequate protein intake is essential for skin repair and maintaining skin integrity. Protein helps in the healing process, supports the immune system, and strengthens the skin, making it more resistant to breakdown. This is a crucial intervention for preventing pressure ulcers and promoting overall skin health in older adults.

B.Massaging bony prominences is not recommended as it can cause friction and damage to already vulnerable skin, increasing the risk of skin breakdown rather than preventing it. Gentle repositioning is preferred to relieve pressure.

C.Clients at risk for skin breakdown should typically be repositioned at least every 2 hours, not every 3 hours, to relieve pressure and reduce the risk of developing pressure ulcers. Therefore, this option is not ideal as stated.

D.While keeping the skin dry is important, cornstarch is not recommended because it can cake and cause friction, which may lead to skin breakdown. Using moisture-wicking products or barrier creams is more appropriate for maintaining skin dryness and integrity.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?

Correct Answer is A

Explanation

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