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 C

Explanation

Allowing time during the workday when each nurse can demonstrate proficiency is the best way to evaluate staff competency with the new equipment. This method ensures that the nurses can perform the skills correctly and safely under the charge nurse’s supervision and feedback.

Choice A is wrong because verbally questioning the staff about the new equipment does not assess their practical skills or ability to use the equipment correctly.

Choice B is wrong because requiring each nurse to take a written examination about the new equipment does not assess their hands-on skills or ability to troubleshoot problems with the equipment.

Choice D is wrong because asking each nurse to read the procedure and sign a form acknowledging competency does not verify that the nurses have understood the procedure or can apply it in practice.

It also relies on the nurses’ honesty and self-assessment, which may not be accurate or reliable.

A. To find the root cause so that the person who is responsible can be identified. B. To protect the nursing staff from litigation. C. To find the root cause so preventative measures can be put in place. D. To determine why the nurses were never told that the patient was a high fall risk.

Correct Answer is C

Explanation

The role of the risk manager is to identify and analyze the factors that contributed to the adverse event and to implement strategies to prevent or reduce the likelihood of recurrence. The risk manager is not concerned with assigning blame or protecting the staff from litigation, but rather with improving the quality and safety of care.

Choice A is wrong because it implies a punitive approach that does not address the underlying system issues.

Choice B is wrong because it suggests a defensive attitude that does not foster a culture of learning and improvement.

Choice D is wrong because it assumes that the nurses were not aware of the patient’s fall risk, which may not be the case.

The risk manager should investigate all aspects of the situation, including the communication and documentation of the patient’s fall risk assessment and interventions.

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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?