A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?

Identify the clients at greatest risk for development of pressure ulcers.

Turn and position each client every 2 hr.

Use a barrier cream when performing perineal care.

Supervise clients to ensure adequate nutritional intake.

Answer and Explanation

The Correct Answer is A

A. Identify the clients at greatest risk for the development of pressure ulcers.
This option emphasizes the importance of individualized care. By identifying clients at the highest risk for pressure ulcers, healthcare providers can tailor preventive measures to address specific risk factors such as immobility, nutritional deficits, and skin conditions.

B. Turn and position each client every 2 hr.
Regular turning and repositioning are crucial in preventing pressure ulcers, especially in individuals with limited mobility. This helps distribute pressure, reducing the risk of skin breakdown. However, this alone may not be sufficient if other risk factors are not addressed.

C. Use a barrier cream when performing perineal care.
Barrier creams can be helpful in protecting the skin from moisture and friction, especially in areas prone to pressure ulcers. While this is a good practice, it may not be the top priority compared to identifying those at the highest risk.

D. Supervise clients to ensure adequate nutritional intake.
Proper nutrition plays a vital role in maintaining skin integrity. Malnutrition can contribute to the development of pressure ulcers. Monitoring and ensuring adequate nutritional intake are important components of prevention but may not be the initial priority.

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Correct Answer is C

Explanation

A. High-fiber cereals:
High-fiber cereals may not be suitable for a soft diet, as they can be challenging to chew and may not meet the texture requirements of a soft diet.

B. Raw vegetables:
Raw vegetables are generally not recommended for a soft diet, as they can be difficult to chew and digest. Cooking or steaming vegetables can make them softer and more suitable for a soft diet.

C. Ground beef:
This is the correct answer. Ground beef can be included in a soft diet, especially if it is cooked to a tender consistency. It provides a good source of protein while meeting the requirements of a soft-textured diet.

D. Fruit with the skin:
Fruits with skins may pose a challenge for individuals on a soft diet, as the skin can be difficult to chew and swallow. Choosing peeled or canned fruits without skins may be more appropriate.

A. Reposition the client every 2 hr. B. Elevate the head of the client's bed 45° C. Massage the client's bony prominences. D. Provide the client with a high-calorie diet.

Correct Answer is A

Explanation

A. Reposition the client every 2hr:
Regular repositioning helps redistribute pressure and prevent tissue damage. Turning the client every 2 hours is even better, especially for those at higher risk.

B. Elevate the head of the client's bed 45°:
Elevating the head of the bed can reduce pressure on the sacral area, which is a common site for pressure injuries. However, this alone is not sufficient, and regular repositioning should still be implemented.

C. Massage the client's bony prominences:
Massaging bony prominences can cause friction and shear, potentially increasing the risk of skin breakdown. This action is generally not recommended.

D. Provide the client with a high-calorie diet:
While proper nutrition is important for overall health, a high-calorie diet alone may not directly prevent pressure injuries. Adequate protein intake is particularly crucial for tissue repair and skin integrity.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with teaching a client who is on a soft diet. Which of the following foods should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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