The client is at risk for impaired skin integrity related to the need for several weeks of bed rest. The nurse evaluates the client after one week and finds the skin integrity is not impaired. In evaluating the plan of care, what is the nurse’s best action?

Remove the nursing diagnosis in the plan of care since it has not occurred.

Keep the nursing diagnosis in the plan of care the same since the risk factors are still present.

Modify the nursing diagnosis in the plan of care to impaired skin integrity.

Change the nursing diagnosis in the plan of care to impaired mobility.

Answer and Explanation

The Correct Answer is B

Choice A reason: Removing the nursing diagnosis in the plan of care since it has not occurred is not a good action, because it does not account for the possibility of future impairment. The client is still at risk for impaired skin integrity due to the prolonged bed rest, and the nurse should continue to monitor and prevent any skin breakdown.

Choice B reason: Keeping the nursing diagnosis in the plan of care the same since the risk factors are still present is the best action, because it reflects the current situation and the potential problem. The client has not developed impaired skin integrity, but the risk factors have not changed. The nurse should maintain the interventions that have been effective in preventing skin impairment, such as turning, repositioning, moisturizing, and inspecting the skin.

Choice C reason: Modifying the nursing diagnosis in the plan of care to impaired skin integrity is not a good action, because it does not match the data. The client has not shown any signs of impaired skin integrity, such as redness, blanching, breakdown, or ulceration. The nurse should not change the diagnosis based on assumptions or predictions, but on evidence.

Choice D reason: Changing the nursing diagnosis in the plan of care to impaired mobility is not a good action, because it does not address the original problem. The client may have impaired mobility due to the bed rest, but that is not the focus of the question. The question is about the risk for impaired skin integrity, which is a different issue that requires different interventions. The nurse should not ignore or replace the existing diagnosis without justification.

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Correct Answer is A

Explanation

Choice A reason: Using standard precautions is a practice that is recommended to prevent HIV transmission, because it is a set of guidelines that apply to all clients, regardless of their infection status, and that aim to prevent the exposure to blood, body fluids, or other potentially infectious materials. Standard precautions include hand hygiene, use of personal protective equipment, safe handling and disposal of sharps, environmental cleaning, and respiratory hygiene.

Choice B reason: Double gloving is not a practice that is recommended to prevent HIV transmission, because it is not proven to be more effective or safer than single gloving. Double gloving is a technique that involves wearing two pairs of gloves, one over the other, which may provide some extra protection against needlestick injuries or glove punctures, but may also reduce the tactile sensitivity, dexterity, or comfort of the wearer. Double gloving is not a routine practice, but rather an option for certain situations, such as highrisk procedures, long surgeries, or known HIVpositive clients.

Choice C reason: Applying hand sanitizer to gloves during cares is not a practice that is recommended to prevent HIV transmission, because it is not appropriate or hygienic. Applying hand sanitizer to gloves during cares is a practice that can damage the integrity and effectiveness of the gloves, as the alcohol or other chemicals can degrade the material, cause holes, or reduce the fit of the gloves. Applying hand sanitizer to gloves during cares can also create a false sense of security, as the gloves may still be contaminated or ineffective. Hand sanitizer should be applied to the hands before and after wearing gloves, not to the gloves themselves.

Choice D reason: Wearing a mask within three feet of the client is not a practice that is recommended to prevent HIV transmission, because it is not necessary or relevant. Wearing a mask within three feet of the client is a practice that is part of the droplet precautions, which are used to prevent the transmission of infections that are spread by large respiratory droplets, such as influenza, pertussis, or meningitis. HIV is not transmitted by respiratory droplets, but rather by sexual contact, blood, or other body fluids. Wearing a mask within three feet of the client may not provide any protection against HIV, and may also cause stigma or discrimination.

A. A client with a urinary tract infection who has a fever of 38.5°C and flank pain B. A client with a deep vein thrombosis who has a positive Homans' sign and edema in the affected leg C. A client with a myocardial infarction who has chest pain and shortness of breath D. A client with a stroke who has slurred speech and facial droop

Correct Answer is C

Explanation

Choice A reason: This is not the highest priority client because a urinary tract infection (UTI) is a common and treatable condition that affects the lower urinary system, such as the bladder or urethra. A fever of 38.5°C and flank pain can indicate that the infection has spread to the upper urinary system, such as the kidneys, which can cause pyelonephritis. Pyelonephritis is a serious but not lifethreatening complication that requires antibiotic therapy and hydration. The nurse should monitor the client's vital signs, urine output, and pain level and administer the prescribed medication and fluids.

Choice B reason: This is not the highest priority client because a deep vein thrombosis (DVT) is a blood clot that forms in a deep vein, usually in the lower extremities. A positive Homans' sign and edema in the affected leg can indicate that the clot is causing inflammation and obstruction of the blood flow. DVT is a serious but not lifethreatening complication that requires anticoagulant therapy and compression therapy. The nurse should monitor the client's vital signs, leg circumference, and pain level and administer the prescribed medication and stockings.

Choice C reason: This is the highest priority client because a myocardial infarction (MI) is a heart attack that occurs when the blood flow to a part of the heart muscle is blocked, causing tissue damage or death. Chest pain and shortness of breath can indicate that the client is experiencing acute cardiac ischemia, which can lead to cardiac arrest or heart failure. MI is a lifethreatening emergency that requires immediate intervention and treatment. The nurse should activate the rapid response team, monitor the client's vital signs, electrocardiogram, and oxygen saturation, and administer the prescribed medication and oxygen.

Choice D reason: This is not the highest priority client because a stroke is a brain attack that occurs when the blood flow to a part of the brain is interrupted, causing tissue damage or death. Slurred speech and facial droop can indicate that the client is experiencing acute neurological impairment, which can affect their communication and facial expression. Stroke is a serious but not lifethreatening complication that requires prompt evaluation and treatment. The nurse should monitor the client's vital signs, neurological status, and glucose level and administer the prescribed medication and fluids.

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The client is at risk for impaired skin integrity related to the need for several weeks of bed rest. The nurse evaluates the client after one week and finds the skin integrity is not impaired. In evaluating the plan of care, what is the nurse’s best action?

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Naxlex Comprehensive Predictor Exams

Which practice is recommended to prevent human immune deficiency virus (HIV) transmission?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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