A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge?

Requests a referral to a registered dietitian nutritionist.

Raises the head of the bed no more than 45 degrees.

Performs perineal cleansing every 2 hours.

Assesses the client's entire skin surface daily.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A Braden Scale score of 9 indicates a high risk for pressure injury. Requesting a referral to a registered dietitian nutritionist is an evidence-based intervention because poor nutrition, particularly protein and calorie deficiency, is a significant risk factor for skin breakdown and impaired wound healing.

Choice B rationale

Keeping the head of the bed raised no more than 45 degrees is an evidence-based practice to prevent pressure injuries. This position reduces the risk of shear and friction forces on the sacrum, which can lead to tissue damage and pressure ulcer formation.

Choice C rationale

Performing perineal cleansing every 2 hours is not an evidence-based intervention for a Braden Scale score of 9. Frequent cleansing can cause excessive moisture, which macerates the skin and increases the risk of breakdown. Cleansing should be done as needed, not on a rigid schedule.

Choice D rationale

Daily skin assessment is a fundamental and evidence-based intervention for all clients at risk for pressure injuries. A Braden score of 9 signifies a high-risk client, and a daily head-to-toe skin assessment is crucial for early detection of erythema or other signs of skin breakdown.

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Correct Answer is A

Explanation

Choice A rationale

Applying medication after a bath is correct because the skin is hydrated and warm, which enhances the absorption of the topical agent. The open pores and softened stratum corneum allow for better penetration of the medication, maximizing its therapeutic effect on the underlying skin condition.

Choice B rationale

Rubbing the ointment in a circular motion can cause mechanical irritation and friction to the compromised skin, which can worsen the rash. The correct technique is to gently smooth the medication over the affected area in a thin, even layer.

Choice C rationale

Increasing the amount of cream without a prescription can lead to systemic absorption and potential adverse effects, especially with corticosteroid creams. The dosage is carefully prescribed to balance therapeutic effects with minimal risk of side effects. Over-application can also cause skin thinning.

Choice D rationale

Using powder and cornstarch is not recommended for skin conditions, as these substances can trap moisture and debris, creating a medium for bacterial or fungal growth. This can exacerbate the underlying skin condition and increase the risk of secondary infections.

A. Green salad, a banana, whole wheat dinner roll, coffee. B. Chicken breast, broccoli, baked potato, and ice water. C. Vegetable lasagna and green salad, iced tea. D. Hamburger, fruit cup, cookie, and diet pop.

Correct Answer is B

Explanation

Choice A rationale

This meal provides carbohydrates and fiber, but it lacks sufficient protein, which is essential for tissue repair and collagen synthesis. Protein intake is crucial for wound healing. A green salad provides vitamins, but the overall meal composition is not optimal for providing the building blocks necessary for skin and tissue regeneration.

Choice B rationale

This dietary choice is excellent for promoting wound healing. Chicken breast provides a high-quality source of protein, which is essential for rebuilding damaged tissue and forming new collagen. Broccoli provides vitamin C, a co-factor in collagen synthesis, while a baked potato offers carbohydrates for energy to fuel the healing process.

Choice C rationale

Vegetable lasagna and green salad provide some vitamins and nutrients, but they are often lower in protein than meat-based options, especially if the lasagna filling is not fortified with high-protein ingredients like cottage cheese. Protein is a critical macronutrient for tissue repair, and the lack of a concentrated source makes this choice suboptimal.

Choice D rationale

This meal is low in essential nutrients. While a hamburger provides some protein, it is often high in saturated fat. The fruit cup and cookie provide simple sugars, which can lead to inflammation and have minimal nutritional value for wound healing. The diet pop offers no nutritional benefit and may contain artificial ingredients that are not beneficial.

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A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement made by a parent indicates an understanding of the topical application of medications for a skin condition?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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