The RN identifies that a client is at risk for impaired skin integrity.
Which interventions should the nurse add to this client’s plan of care?

Place the patient in a side-lying position only.

Massage bony prominences.

Use positioning devices such as foam wedges.

Keep the head of the bed elevated higher than 30 degrees. E. Inspect skin every shift.

Answer and Explanation

The Correct Answer is C

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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Correct Answer is A

Explanation

This is because people with COPD are more likely to catch respiratory infections such as colds, flu and pneumonia, which can worsen their symptoms and cause further lung damage. An influenza vaccine can help prevent flu and reduce the risk of complications.

Choice B. A broad-spectrum antibiotic is wrong because antibiotics are only effective against bacterial infections, not viral ones. Antibiotics are usually prescribed for COPD exacerbations caused by bacterial infections, but not for prevention.

Choice C. A bronchodilator is wrong because bronchodilators are medications that relax the muscles around the airways and make breathing easier. They are used to treat the symptoms of COPD, but they do not prevent respiratory infections.

Choice D. A corticosteroid is wrong because corticosteroids are anti inflammatory drugs that reduce swelling and mucus production in the airways. They are also used to treat the symptoms of COPD, but they do not prevent respiratory infections. In fact, long-term use of corticosteroids may increase the risk of infections by suppressing the immune system.

A. A client who has a family history of breast cancer is scheduled for a mammogram. B. A client who has heart failure is scheduled for an echocardiogram. C. A client who is asymptomatic is not scheduled for a series of tests. D. A client is scheduled to receive an influenza vaccination.

Correct Answer is A

Explanation

This is an example of secondary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complications. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.

This is an example of tertiary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complication. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

Choice C is wrong because it is not an example of any level of prevention.

A client who is asymptomatic is not scheduled for a series of tests because there is no indication of any disease or risk factor.

Choice D is wrong because it is an example of primary prevention, which is the action taken to prevent the development of disease.

A client who is scheduled to receive an influenza vaccination is protected from getting infected by the virus and developing flu-related complications.

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The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

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The RN identifies that a client is at risk for impaired skin integrity.
Which interventions should the nurse add to this client’s plan of care?