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 C
Explanation
A. Providing the client's breakfast is an essential aspect of diabetes care, but obtaining information about the client's blood glucose level is a priority before administering insulin or making decisions about meal planning.
B. Obtaining the client's capillary blood glucose level is a critical first step. Knowing the current blood glucose level guides the nurse in determining the appropriate insulin dosage, assessing the need for any adjustments in the treatment plan, and planning the client's breakfast based on their current glucose level.
C. Checking the calibration of the glucometer is the first action to ensure the accuracy of the blood glucose measurement. Regular calibration checks help maintain the precision of the glucometer and ensure reliable results.
D. Administering prescribed insulin is an important step in managing type 1 diabetes, but the dosage should be determined based on the client's current blood glucose level. Administering insulin without knowing the current glucose level could lead to inappropriate dosage and potential complications.
Correct Answer is C
Explanation
A. Disinfect hands using an alcohol-based waterless antiseptic:
While alcohol-based hand sanitizers are effective against many germs, including bacteria, they may not be as effective against C. difficile. Soap and water are preferable for hand hygiene in C. difficile cases because alcohol does not effectively kill the spores.
B. Wear an N95 respirator when caring for the client:
The primary mode of transmission for C. difficile is through the fecal-oral route, and respiratory precautions are not necessary. Standard precautions, including wearing gloves and gowns, are generally sufficient.
C. Use diluted bleach to clean soiled equipment:
This is the correct answer. Bleach is an effective disinfectant against C. difficile spores. It is recommended for cleaning surfaces and equipment that may be contaminated.
D. Provide a room with negative-pressure airflow:
Negative-pressure airflow rooms are typically reserved for airborne infections, and they are not necessary for C. difficile. Standard precautions, along with thorough cleaning and disinfection, are the key measures.
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