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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?

A.

Use of the Braden scale for clients who are immobile

B.

Daily weighing of clients who have heart failure

C.

Documentation of PAINAD scale for clients who have dementia

D.

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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Related Questions

Correct Answer is A

Explanation

A. Perform CPR on the client:

CPR (Cardiopulmonary Resuscitation) is a critical and time-sensitive intervention during a cardiac arrest. An assistive personnel trained in CPR can initiate chest compressions while awaiting further medical assistance.

B. Assist with airway intubation:

Airway intubation is a more advanced skill typically performed by healthcare providers such as physicians or advanced practice nurses. It is beyond the scope of practice for most assistive personnel.

C. Maintain IV access:

Maintaining IV access may require specific skills and knowledge about medications and fluids. While some assistive personnel may be trained in certain aspects of IV care, the level of expertise needed during a cardiac arrest may be beyond their scope.

D. Place defibrillator pads on the client:

Applying defibrillator pads involves handling medical equipment and making critical decisions about when to deliver a shock. This task is typically performed by healthcare providers trained in advanced cardiac life support (ACLS).

Correct Answer is ["2.1"]

Explanation

To calculate the total daily dose of tobramycin, we use the formula:

  • Total Daily Dose (mg) = Dose (mg/kg/day) × Weight (kg)
  • Total Daily Dose (mg)=Dose (mg/kg/day)×Weight (kg)

In this case:

  • Total Daily Dose=3 mg/kg/day × 85 kg
  • Total Daily Dose=255mg/day

Since the total daily dose is divided into three doses, the nurse should administer:

  • Dose per Administration =Total Daily Dose/Number of Doses per Day
  • Dose per Administration = 255 mg/3
  • Dose per Administration≈85mg

Now, to calculate the volume (mL) to administer, we use the concentration of the available tobramycin solution:

  • Volume (mL)=Dose per Administration (mg)/Concentration (mg/mL)

In this case:

  • Volume=85mg/40mg/mL
  • Volume≈2.1mL

Therefore, the nurse should administer approximately 2.1 mL of tobramycin per dose, rounded to the nearest tenth.

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