A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document as decreasing the risk for skin breakdown?

Use of the Braden scale for clients who are immobile

Daily weighing of clients who have heart failure

Documentation of PAINAD scale for clients who have dementia

Implementation of incentive spirometry for clients who are postoperative

Answer and Explanation

The Correct Answer is A

A. Use of the Braden scale for clients who are immobile.

The Braden Scale is a widely used tool for assessing the risk of pressure ulcer development. It includes various factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear. For clients who are immobile, the Braden Scale helps identify their risk for skin breakdown and guides the implementation of preventive measures.

B. Daily weighing of clients who have heart failure:

Daily weighing of clients with heart failure is important for monitoring fluid status, but it is not specifically focused on decreasing the risk of skin breakdown. Skin breakdown is more closely related to factors such as immobility, pressure, and friction.

C. Documentation of PAINAD scale for clients who have dementia:

The PAINAD scale is used to assess pain in clients with advanced dementia. While managing pain is important for overall well-being, it is not a direct measure for decreasing the risk of skin breakdown. Skin breakdown prevention is more related to factors like pressure relief and moisture management.

D. Implementation of incentive spirometry for clients who are postoperative:

Incentive spirometry is primarily aimed at promoting lung expansion and preventing respiratory complications after surgery. While postoperative care is essential, it does not directly address the risk of skin breakdown. Skin breakdown prevention involves interventions related to pressure relief, repositioning, and skin care.

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Free Nursing Study Resources

Correct Answer is ["38"]

Explanation

To calculate the IV flow rate in drops per minute (gtt/min), you can use the following formula:

Flow Rate (gtt/min)=(Volume (mL)/Time (min)) × Drop Factor (gtt/mL)

In this case:

Flow Rate = (150 mL/hr / 60 min/hr) × 15 gtt/mL

Flow Rate=37.5gtt/min

Therefore, the nurse should set the IV flow rate to deliver approximately 38 gtt/min for the dextrose 5% in water IV infusion at 150 mL/hr, rounded to the nearest whole number.

A. Instruct the client to limit flexion of the hips no further than 100". B. Perform range-of-motion exercises every 2 hr. C. Reposition the client every 2 hr. D. Place an abduction pillow between the legs.

Correct Answer is A

Explanation

A. Instruct the client to limit flexion of the hips no further than 100°.For a client who is postoperative following a total hip arthroplasty, hip flexion should generally be limited to 90° or less to avoid dislocation of the hip prosthesis. The instruction to limit flexion to 100° could potentially put the client at risk for dislocation and should be clarified.

B. Perform range-of-motion exercises every 2 hr.This helps prevent stiffness and promotes circulation, although passive range of motion should be performed carefully to avoid excessive hip flexion.

C. Reposition the client every 2 hr.Regular repositioning helps prevent pressure ulcers and other complications, and is a standard postoperative practice.

D. Place an abduction pillow between the legs.An abduction pillow is used to keep the legs apart and prevent dislocation of the hip joint, which is essential after a hip arthroplasty.

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A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document as decreasing the risk for skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["38"]

Explanation

A nurse is reviewing the prescriptions for a client who is postoperative following a total hip arthroplasty. Which of the following prescriptions should the nurse clarify with the provider?

Correct Answer is A

Explanation

A nurse is preparing to administer promethazine 25 mg IM to a client. Available is promethazine 50 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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