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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Disinfecting hands using an alcohol-based waterless antiseptic is not effective against Clostridium difficile spores. C. difficile is a bacterium that forms spores, which are resistant to alcohol-based hand sanitizers. Handwashing with soap and water is recommended for effective removal of the spores.
B. Wearing an N95 respirator is not specifically indicated for caring for clients with Clostridium difficile. The primary mode of transmission for C. difficile is fecal-oral, and standard precautions, including gloves and gowns, are usually sufficient. N95 respirators are more commonly used for airborne precautions.
C. Using diluted bleach to clean soiled equipment is the correct instruction. Clostridium difficile spores are resistant to many disinfectants, but bleach (sodium hypochlorite) is effective in killing C. difficile spores. Diluted bleach solutions are recommended for cleaning surfaces and equipment that may be contaminated with C. difficile.
D. Providing a room with negative-pressure airflow is not typically necessary for clients with Clostridium difficile. Standard precautions, including appropriate cleaning and disinfection, are generally sufficient to prevent the spread of C. difficile in healthcare settings.
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