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 D
Explanation
A. Complete medication reconciliation when a client moves to a new room on the same unit:
While it's important to update the client's information when they change rooms, this may not necessitate a full medication reconciliation. Medication reconciliation is typically more comprehensive and involves a thorough review of the client's entire medication regimen.
B. Medication reconciliation should be completed whenever the nurse administers a medication:
While it's important to verify medications before administration, a full medication reconciliation involves a broader review of the client's entire medication history and should not necessarily be done each time a single medication is administered.
C. Medication reconciliation can be delegated to an assistive personnel:
Medication reconciliation is a complex process that involves a thorough review of the client's medication history, and it is generally considered a nursing responsibility. Delegating this task to assistive personnel may compromise accuracy and completeness.
D. Include herbal supplements in the medication reconciliation:
This is the correct answer. Herbal supplements can interact with prescribed medications and may impact the client's overall health. Including them in the medication reconciliation process ensures a comprehensive assessment of the client's medication regimen.
Correct Answer is C
Explanation
A. While reporting the fire details to the facility emergency extension is important, the immediate action to ensure the safety of everyone in the facility is to activate the fire alarm. Activating the fire alarm alerts the entire facility to the presence of a fire and initiates the appropriate emergency response.
B. Closing the door to the client's room is a secondary action and can be done after activating the fire alarm. However, the priority is to activate the fire alarm to quickly notify others about the potential danger.
C. Activating the fire alarm is the immediate action to take in the event of a fire. This step ensures that the fire response team is alerted, and appropriate emergency measures are initiated promptly.
D. Turning off electrical equipment can be a safety measure, but it is not the first priority when there is an active fire. Activating the fire alarm and ensuring the evacuation of individuals from the area take precedence.
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