A nurse is assessing a client's risk for pressure injuries using the Braden Scale. The client is bedridden, has a poor appetite, and frequently slides down in bed. Which Braden Scale category should be prioritized to address immediate interventions?
Nutrition
Activity
Sensory Perception
Friction and Shear
The Correct Answer is D
A. Nutrition: Poor nutrition increases the risk of skin breakdown over time by impairing tissue repair and skin integrity. While important, nutrition is a longer-term risk factor and does not address the client’s immediate mechanical risk.
B. Activity: Reduced mobility contributes to pressure injury development, but it is a broader category encompassing overall movement. The client’s sliding in bed specifically increases friction and shear forces, which require more immediate intervention.
C. Sensory Perception: Sensory deficits affect the client’s ability to feel discomfort and reposition independently. Although relevant, the client’s issue is primarily mechanical rather than related to sensory awareness.
D. Friction and Shear: The client frequently slides down in bed, directly increasing friction and shear on the sacral area. Addressing this category with interventions such as repositioning devices, proper support surfaces, and transfer techniques is critical to prevent immediate tissue injury.
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Related Questions
Correct Answer is D
Explanation
A. By focusing only on clinical guidelines: Clinical guidelines are a component of evidence-based practice, but EBP integrates research evidence, clinical expertise, and patient preferences. Relying solely on guidelines may not fully optimize outcomes.
B. By increasing healthcare costs: Evidence-based practice aims to improve efficiency, reduce unnecessary interventions, and enhance outcomes, which can lower costs over time. It does not inherently increase healthcare expenditures.
C. By solely relying on clinician experience: While clinical expertise is important, relying only on personal experience may introduce bias or outdated practices. EBP combines experience with current, high-quality research for best outcomes.
D. By using the most accurate scientific evidence in clinical decisions: Utilizing validated research findings allows healthcare providers to implement interventions proven to be effective, reducing errors and improving safety, quality of care, and overall client outcomes.
Correct Answer is B
Explanation
A. Manually override the lab results to remove the red rotation: Altering or overriding abnormal lab results without proper review is unsafe and violates professional and legal standards. It can lead to missed critical interventions and endanger patient safety.
B. Immediately notify the healthcare provider about the abnormal results: Abnormal lab values, especially those flagged as critical, require prompt communication to the provider. Timely notification ensures appropriate assessment, intervention, and prevention of potential complications. This action prioritizes patient safety.
C. Print the lab results and file them without taking further action: Filing abnormal results without notifying the provider delays necessary treatment and compromises patient care. Documentation alone does not address the immediate clinical significance of abnormal findings.
D. Ignore the results and wait for the next scheduled follow-up: Ignoring critical lab results can lead to deterioration of the patient’s condition. Active response to abnormal findings is a professional responsibility to ensure timely interventions.
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