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 A

Explanation

A. In team nursing, an RN assumes the role of a team leader or coordinator. The RN oversees and coordinates the care provided by other team members, which may include licensed practical nurses (LPNs), nursing assistants, and other healthcare professionals. The team collaborates to meet the needs of a group of clients.

B. Caring for the same clients throughout their hospitalization is more characteristic of primary nursing, where an RN takes primary responsibility for the care of a specific group of clients.

C. Linking community resources with clients to ensure quality care is more aligned with case management or community health nursing, where the focus is on coordinating services across healthcare settings and connecting clients with appropriate resources.

D. Providing every aspect of care for a group of clients during a shift is not consistent with team nursing. In team nursing, the workload is distributed among team members, and an RN typically coordinates and oversees the care provided by the team.

A. "Have you scheduled an appointment with the prosthetist?" B. "Do you feel your pain is controlled well? C. "Are you aware of any support groups in the area?" D. "Have you been exercising your other extremities?"

Correct Answer is B

Explanation

A. While scheduling an appointment with the prosthetist is important, the client's comfort and pain control take precedence, especially in the immediate postoperative period. Addressing pain concerns is a priority to ensure the client's well-being.

B. "Do you feel your pain is controlled well?" is the first question to ask. Assessing pain is crucial to understanding the client's level of comfort and ensuring that appropriate measures are in place for pain management. This information can guide further interventions and adjustments to the care plan.

C. Inquiring about support groups in the area is an important aspect of the client's overall well-being and adjustment to the amputation. However, pain control is an immediate concern, and addressing it takes precedence during the initial home visit.

D. Asking about exercising other extremities is relevant for the client's overall mobility and

rehabilitation. However, pain control assessment should be prioritized as it directly impacts the client's ability to participate in rehabilitation activities.

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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

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Correct Answer is B

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