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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
To calculate the volume (mL) that the nurse should administer, you can use the following formula:
Volume (mL) = Dose (mg)/Concentration (mg/mL)
In this case:
Volume = 500 mg/(250 mg/5 mL)
First, simplify the fraction:
Volume = 500mg/50 mg/mL
Now, determine the volume:
Volume =(500 mg/50 mg/mL)×(1 mL/1mg)
Volume=10mL
Therefore, the nurse should administer 10 mL of amoxicillin oral suspension for the 500 mg PO dose, rounded to the nearest whole number.
Correct Answer is B
Explanation
A.While it is important to have nonperishable food items, they should generally be checked and rotated every 6 months to a year to ensure they remain within expiration dates and to maintain freshness. Depending on storage conditions, some items may degrade sooner, so this timeframe may be insufficient.
B.In a disaster situation, access to pharmacies may be limited, so having a backup supply of essential nonprescription medications like pain relievers, antacids, and allergy medications is essential. This ensures that individuals have what they need to manage minor health issues without needing immediate access to stores.
C.Current recommendations typically advise having enough supplies for at least 3 days (72 hours) to a week, as this is generally the period required before external help may arrive during a disaster. While gathering supplies for two weeks can be helpful, it may not be feasible for everyone due to storage limitations.
D.The recommended amount of water for emergency situations is 1 gallon (approximately 3.8 liters) per person per day, which accounts for drinking and basic hygiene needs. Two liters would not be sufficient for most people’s daily water needs during an emergency.
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