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.
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Related Questions
Correct Answer is A
Explanation
A. Facility policy and procedure manual.
The facility policy and procedure manual is the primary resource for step-by-step directions to clean up a chemical spill within a specific healthcare setting. Each healthcare facility has its own policies and procedures outlining the appropriate steps to take in the event of a chemical spill to ensure the safety of both patients and healthcare providers.
B. Poison Control Center:
The Poison Control Center is a valuable resource for information related to poisoning, but it may not provide specific step-by-step directions for cleaning up a chemical spill. Its primary focus is on managing exposures and providing advice on the treatment of poisonings.
C. Safety data sheet (SDS):
The Safety Data Sheet provides information about the properties of a chemical substance. While it offers details about the chemical and its hazards, it is not typically used as a step-by-step guide for cleaning up a spill. The SDS is more focused on providing information about the chemical's properties, safety precautions, and emergency response measures.
D. The National Quality Forum:
The National Quality Forum is a healthcare organization that focuses on healthcare quality improvement. It is not a primary resource for specific step-by-step directions for handling a chemical spill. Facility-specific policies and procedures are more appropriate for this purpose.
Correct Answer is B
Explanation
A. Completing an incident report is an important step to document the error, but the immediate priority is to assess the client's condition and address any potential adverse effects. Incident reporting can follow once the immediate assessment and interventions are completed.
B. Checking the client's vital signs is the first action to take. The nurse needs to assess the client's physiological response to the double dose, as some medications can have significant effects on vital signs. Monitoring vital signs provides crucial information to determine the client's stability and whether additional interventions are needed.
C. Notifying the charge nurse of the error is an important step, but checking the client's vital signs takes precedence to ensure the client's immediate safety. The charge nurse can be informed after the initial assessment.
D. Documenting the facts of the incident in the nurse's notes is important, but it comes after assessing the client and taking immediate actions to address any potential harm. Documenting the incident helps maintain a comprehensive record and contributes to the overall understanding of the event.
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