The RN identifies that a client is at risk for impaired skin integrity.
Which interventions should the nurse add to this client’s plan of care?

Place the patient in a side-lying position only.

Massage bony prominences.

Use positioning devices such as foam wedges.

Keep the head of the bed elevated higher than 30 degrees. E. Inspect skin every shift.

Answer and Explanation

The Correct Answer is C

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.

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Correct Answer is D

Explanation

Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia that can cause muscle rigidity, fever, and a fast heart rate. It can be fatal if not treated promptly with medication, oxygen, body cooling, and supportive care. The patient’s symptoms match those of malignant hyperthermia.

Choice A is wrong because alpha-1 antitrypsin deficiency is a genetic disorder that affects the lungs and liver, causing shortness of breath, wheezing, and jaundice.

It does not cause a rise in body temperature or muscle rigidity. Choice B is wrong because malignant hypothermia does not exist. It is a misspelling of malignant hyperthermia.

Choice C is wrong because thalassemia is a genetic disorder that affects the production of hemoglobin, causing anemia, fatigue, and bone deformities.

It does not cause a rise in body temperature or muscle rigidity.

A. The nurse refuses care of the client. B. The nurse delegates all care of the client to an assistant. C. The nurse provides minimal care to keep the client alive. D. The nurse cares for the patient in the same manner as for other clients.

Correct Answer is D

Explanation

This aligns with the professional code of ethics for nurses, which states that nurses should respect the dignity, worth and rights of all human beings, regardless of the nature of their health problems or their social or legal status. The nurse should not let personal feelings or biases interfere with the quality of care or the ethical obligations of the profession.

Choice A is wrong because the nurse refuses to care of the client. This violates the principle of beneficence, which means doing good and preventing harm to others.

The nurse has a duty to provide care to all patients who need it, regardless of their personal opinions or feelings.

Choice B is wrong because the nurse delegates all care of the client to an assistant. This violates the principle of accountability, which means being answerable for one’s actions and decisions. The nurse cannot delegate tasks that require nursing judgment or assessment to an unlicensed person.

The nurse is responsible for ensuring that the patient receives safe and competent care.

Choice C is wrong because the nurse provides minimal care to keep the client alive. This violates the principle of non-maleficence, which means avoiding harm or injury to others.

The nurse should not provide substandard care or neglect the patient’s needs or preferences.

The nurse should strive to promote the health and well-being of the patient.

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The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client is hospitalized and is in police custody after being arrested for driving while intoxicated for the third time. The nurse assigned to the client lost her brother to a drunk driver two years prior. Which action on the part of the nurse aligns with the professional code of ethics for nurses?

Correct Answer is D

Explanation

A nurse is assisting with teaching a newly licensed nurse about ethical principles. The nurse should include that working to not cause harm to a client, while trying to achieve the best possible outcome, is an example of which of the following ethical principles?

An elderly client is admitted to the hospital looking unkempt, with dirty clothing, and she smells of urine. The nurse is aware this may be:

A nurse is teaching a newly licensed nurse about informed consent. Which of the following should be included as a responsibility of the nurse in this process?

A client sees his primary care physician for complaints of fatigue. Bloodwork shows the client is anemic. Upon physical assessment, what signs would the provider expect to see? (Select all that apply)

Which of the following nursing diagnoses would typically NOT be associated with anemia?

A nurse is caring for a patient who has complaints of fatigue. If the fatigue is caused by lifestyle choices, what should the nurse recommend for fatigue prevention? (Select all that apply)

The nurse knows that infants have a high risk of hypothermia due to decreased brown fat, immature skin, and poorly developed thermoregulatory mechanism. Which nursing intervention is done to prevent heat loss by conduction?

A nurse is preparing to administer a medication to a client. Which of the following actions by the nurse demonstrates advocacy for client rights?

The RN identifies that a client is at risk for impaired skin integrity.
Which interventions should the nurse add to this client’s plan of care?