A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document as decreasing the risk for skin breakdown?

Use of the Braden scale for clients who are immobile

Daily weighing of clients who have heart failure

Documentation of PAINAD scale for clients who have dementia

Implementation of incentive spirometry for clients who are postoperative

Answer and Explanation

The Correct Answer is A

A. Use of the Braden scale for clients who are immobile.

The Braden Scale is a widely used tool for assessing the risk of pressure ulcer development. It includes various factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear. For clients who are immobile, the Braden Scale helps identify their risk for skin breakdown and guides the implementation of preventive measures.

B. Daily weighing of clients who have heart failure:

Daily weighing of clients with heart failure is important for monitoring fluid status, but it is not specifically focused on decreasing the risk of skin breakdown. Skin breakdown is more closely related to factors such as immobility, pressure, and friction.

C. Documentation of PAINAD scale for clients who have dementia:

The PAINAD scale is used to assess pain in clients with advanced dementia. While managing pain is important for overall well-being, it is not a direct measure for decreasing the risk of skin breakdown. Skin breakdown prevention is more related to factors like pressure relief and moisture management.

D. Implementation of incentive spirometry for clients who are postoperative:

Incentive spirometry is primarily aimed at promoting lung expansion and preventing respiratory complications after surgery. While postoperative care is essential, it does not directly address the risk of skin breakdown. Skin breakdown prevention involves interventions related to pressure relief, repositioning, and skin care.

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Correct Answer is ["C","D"]

Explanation

A. "I should wait until I am terminally ill to complete my advance directives."

This statement is incorrect. It is advisable to complete advance directives before a critical or terminal illness occurs to ensure that one's preferences are known and respected in the event of incapacity.

B. "I must name a relative to make decisions for me in my health care proxy."

This statement is incorrect. While naming a relative is a common choice, individuals can choose any competent person as their healthcare proxy, and it does not have to be a family member.

C. "I can state in my living will which medical treatments I want done if I am terminally ill."

This statement is correct. A living will allows individuals to specify the medical treatments they wish to receive or avoid in the event they become terminally ill or incapacitated.

D. "I will make changes to my advance directives if I change my mind about anything."

This statement is correct. Advance directives are not permanent and can be changed or updated if the individual's preferences or circumstances change.

E. "I will need to complete a new living will each time I am hospitalized."

This statement is incorrect. Advance directives, including living wills, are generally not tied to a specific hospitalization. They remain in effect unless the individual chooses to update or change them.

Correct Answer is ["0.75"]

Explanation

To calculate the volume (mL) that the nurse should administer, you can use the following formula:

Volume (mL) = Dose (mg)/Concentration (mg/mL)

In this case:

Volume=7.5 mg/10 mg/mL

Volume=0.75mL

Therefore, the nurse should administer 0.75 mL of morphine for the 7.5 mg subcutaneous dose, rounded to the nearest hundredth.

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A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document as decreasing the risk for skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

A nurse is preparing to administer morphine 7.5 mg subcutaneous. Available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.75"]

Explanation

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