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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["38"]

Explanation

To calculate the IV flow rate in drops per minute (gtt/min), you can use the following formula:

Flow Rate (gtt/min)=(Volume (mL)/Time (min)) × Drop Factor (gtt/mL)

In this case:

Flow Rate = (150 mL/hr / 60 min/hr) × 15 gtt/mL

Flow Rate=37.5gtt/min

Therefore, the nurse should set the IV flow rate to deliver approximately 38 gtt/min for the dextrose 5% in water IV infusion at 150 mL/hr, rounded to the nearest whole number.

A. Perform CPR on the client. B. Assist with airway intubation. C. Maintain IV access. D. Place defibrillator pads on the client.

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).

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is ["38"]

Explanation

A nurse is assisting with the care of a client who is experiencing a cardiac arrest. Which of the following tasks should the nurse assign to an assistive personnel?

Correct Answer is A

Explanation

A nurse is preparing to administer methotrexate 7.5 mg subcutaneous for a client who has rheumatoid arthritis. Available is methotrexate 15 mg/0.4 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A charge nurse is reinforcing teaching with a newly licensed nurse about the confidentiality of clients' electronic health records. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is preparing to administer chlorpromazine 0.55 mg/kg IM to a child who weighs 66 lb. Available is chlorpromazine 25 mg/mL for injection. How many mL should the nurse administer? (Round the answer to the nearest tenths. Use a leading zero if it applies. Do not use a trailing zero.)

A murse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her ad daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

A nurse is assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?

A nurse is preparing to administer levothyroxine 150 mcg PO. Available is levothyroxine 75 mcg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse in a long-term care facility is reinforcing teaching with a newly licensed nurse about chemotherapy-induced nausea. Which of the following food selections indicates the newly licensed nurse understands the teaching?

A nurse is preparing to witness a client sign a consent for a laparoscopic total cholecystectomy. The nurse should delay obtaining the signature and notify the provider if the client makes which of the following statements?