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 A

Explanation

One of the highest levels of evidence are randomized, controlled, double-blind studies. This is because these studies reduce the risk of bias and confounding factors by randomly assigning participants to intervention or control groups, blinding the participants and researchers to the group allocation, and using a placebo or standard treatment as a comparison.

Choice B is wrong because ideas, editorials, and opinions are considered low levels of evidence as they are based on personal views and not on rigorous research methods.

Choice C is wrong because the purpose of the hierarchy of evidence is to help the nurse evaluate the quality and strength of the research findings, not to compare patient values with research findings.

Patient values are important for evidence-based practice, but they are not part of the hierarchy of evidence.

Choice D is wrong because all forms of evidence should not be considered equally when determining evidence-based practice. The hierarchy of evidence ranks different types of research designs according to their validity and applicability, and the nurse should use the highest level of evidence available for their clinical question.

A. A client who has a family history of breast cancer is scheduled for a mammogram. B. A client who has heart failure is scheduled for an echocardiogram. C. A client who is asymptomatic is not scheduled for a series of tests. D. A client is scheduled to receive an influenza vaccination.

Correct Answer is A

Explanation

This is an example of secondary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complications. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.

This is an example of tertiary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complication. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

Choice C is wrong because it is not an example of any level of prevention.

A client who is asymptomatic is not scheduled for a series of tests because there is no indication of any disease or risk factor.

Choice D is wrong because it is an example of primary prevention, which is the action taken to prevent the development of disease.

A client who is scheduled to receive an influenza vaccination is protected from getting infected by the virus and developing flu-related complications.

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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

A charge nurse is discussing evidence-based practice (EBP) with a newly licensed nurse. Which of the following information should the nurse include when discussing the hierarchy of evidence?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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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?