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 ["B","C","D"]

Explanation

These are signs of anemia, which is a condition in which the blood lacks enough healthy red blood cells to carry adequate oxygen to the body’s tissues.

Anemia can cause fatigue, weakness, pale skin, cold hands and feet, dizziness, reduced immunity and shortness of breath.

Choice A is wrong because bradypnea is abnormally slow breathing, which is not a sign of anemia. Anemia can cause tachypnea, which is abnormally fast breathing.

Choice E is wrong because flushed skin is not a sign of anemia. Anemia can cause pallor, which is pale or yellowish skin.

Flushed skin can be a sign of other conditions, such as fever, infection or allergic reaction.

Normal ranges for hemoglobin levels vary depending on age and gender. For adult males, the normal range is 13.5 to 17.5 grams per deciliter (g/dL) of blood. For adult females, the normal range is 12 to 15.5 g/dL of blood.

A. Review all ordered treatments in relation to the client’s culture. B. Listen to the client’s perceptions. C. Explain the purpose of the treatments, without regard to the client’s culture. D. Acknowledge that the client will have to adapt their perceptions to the dominant culture.

Correct Answer is ["A","B"]

Explanation

A cultural assessment is a systematic way to identify the beliefs, values, meanings, and behaviours of people while considering their history, life experiences, and social and physical environments. A nurse should include reviewing all ordered treatments in relation to the client’s culture and listening to the client’s perceptions as part of a cultural assessment.

These actions show respect for the client’s preferences and facilitate communication and understanding.

Choice C is wrong because explaining the purpose of the treatments without regard to the client’s culture may be insensitive or inappropriate for some clients who have different beliefs or practices about health and illness. Choice D is wrong because acknowledging that the client will have to adapt their perceptions to the dominant culture may be disrespectful or oppressive for some clients who value their cultural identity and diversity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client sees his primary care physician for complaints of fatigue. Bloodwork shows the client is anemic. Upon physical assessment, what signs would the provider expect to see? (Select all that apply)

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

Explanation

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Correct Answer is ["A","B"]

Explanation

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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?