A new nurse is working in a hospital.
Which of the following actions by the nurse is NOT related to one of the National Patient Safety Goals?

This statement indicates an understanding of the ethical principle of respect for autonomy, which means that the nurse respects the client’s right to make their own decisions about their care and respects their values and beliefs.

Choice A is wrong because “A nurse’s personal values are not considered when making ethical decisions.” This statement contradicts the ethical principle of integrity, which means that the nurse acts in accordance with their personal and professional values and standards.

Choice B is wrong because “A nurse’s behaviors and actions are called values.” This statement confuses values with morals, which are the judgments about behaviors and actions based on personal or societal beliefs.

Choice D is wrong because “Value clarification involves maintaining clinical competency.” This statement confuses value clarification with professionalism, which involves maintaining clinical competency, accountability, and responsibility. Value clarification is a process of self-exploration and reflection that helps the nurse identify their own values and understand how they affect their ethical decisions.

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.