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

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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Correct Answer is B

Explanation

A. While scheduling an appointment with the prosthetist is important, the client's comfort and pain control take precedence, especially in the immediate postoperative period. Addressing pain concerns is a priority to ensure the client's well-being.

B. "Do you feel your pain is controlled well?" is the first question to ask. Assessing pain is crucial to understanding the client's level of comfort and ensuring that appropriate measures are in place for pain management. This information can guide further interventions and adjustments to the care plan.

C. Inquiring about support groups in the area is an important aspect of the client's overall well-being and adjustment to the amputation. However, pain control is an immediate concern, and addressing it takes precedence during the initial home visit.

D. Asking about exercising other extremities is relevant for the client's overall mobility and

rehabilitation. However, pain control assessment should be prioritized as it directly impacts the client's ability to participate in rehabilitation activities.

A. Discard any remaining medication after 10 days. B. Use 0.9% sodium chloride solution as a diluent. C. Roll the vial gently in hands to mix the medication. D. Store the medication at room temperature following reconstitution

Correct Answer is A

Explanation

A. Discard any remaining medication after 10 days:

This is the correct action according to the label. The label specifies that the reconstituted suspension should be discarded after 10 days, emphasizing the importance of not using the medication beyond that period for safety reasons.

B. Use 0.9% sodium chloride solution as a diluent:

The label does not mention the use of 0.9% sodium chloride solution. It specifically provides directions for adding water for reconstitution. Therefore, using sodium chloride solution is not consistent with the instructions.

C. Roll the vial gently in hands to mix the medication:

The label instructs to "Shake vigorously" to wet the powder, not to roll it gently. Shaking is the recommended method for mixing the medication according to the label.

D.Store the medication at room temperature following reconstitution:

The label clearly states that the reconstituted suspension "Must be refrigerated." Storing it at room temperature contradicts the provided instructions

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing for a home visit with a client who is postoperative following an above-the-knee amputation. Which of the following questions should the nurse plan to ask first?

Correct Answer is B

Explanation

A nurse is preparing to reconstitute amoxicillin/clavulanate potassium oral suspension to administer to a client who has a respiratory tract infection. According to the label, which of the following actions should the nurse take? (Refer to the medication label below.)

Correct Answer is A

Explanation

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