A nurse is caring for a patient with a BMI of.
Appropriate nursing interventions include:

Hourly vital signs.

Implementing all fall risk precautions.

Utilizing bariatric bed and trapeze bar.

Supine positioning.

Answer and Explanation

The Correct Answer is C

A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.

These interventions can promote comfort, safety, and independence for the patient.

Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.

Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.

Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration.

The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.

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Correct Answer is C

Explanation

Giving a report to a provider in SBAR format is not related to one of the National Patient Safety Goals (NPSGs). The NPSGs are a set of standards developed by The Joint Commission to improve patient safety andquality of care. They address specific areas of concern such as infection prevention, medication safety, patient identification, communication, and alarm management.

Choice A is wrong because refraining from changing alarm settings is related to NPSG 06.01.01, which aims to improve the safety of clinical alarm systems. Choice B is wrong because using 2 patient identifiers for medication administration is related to NPSG 01.01.01, which aims to improve the accuracy of patient identification.

Choice D is wrong because arriving 15 minutes prior to the start of the shift is related to NPSG 02.03.01, which aims to improve the effectiveness of communication among caregivers.

A. Place the patient in a side-lying position only. B. Massage bony prominences. C. Use positioning devices such as foam wedges. D. Keep the head of the bed elevated higher than 30 degrees. E. Inspect skin every shift.

Correct Answer is C

Explanation

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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A nurse is caring for a patient with a BMI of. Appropriate nursing interventions include:

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A nurse is caring for a patient with a BMI of.
Appropriate nursing interventions include: