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 means that the blood flow to the affected area is reduced due to narrowed or blocked arteries. This can cause tissue death or gangrene. Diabetes can

damage the blood vessels and affect blood flow, increasing the risk of gangrene. Choice B. Stasis is wrong because it refers to a condition where blood pools in the veins of the legs, causing swelling and skin changes. It does not cause gangrene by itself.

Choice C. Venous insufficiency is wrong because it refers to a condition where the veins in the legs have problems sending blood back to the heart, causing swelling and skin ulcers. It does not cause gangrene by itself.

Choice D. Varicose veins are wrong because they are enlarged veins that may cause pain or discomfort, but do not cause gangrene by themselves.

A. Encouraging the client to verbalize questions or concerns. B. Telling the client that refusal of the medication is considered noncompliance. C. Informing the client that the medication is the same as taken at home. D. Insisting the client takes the prescribed medications.

Correct Answer is A

Explanation

This demonstrates advocacy for client rights because it respects the client’s autonomy, dignity, and preferences. It also helps the client to make informed decisions about their own health.

Choice B is wrong because telling the client that refusal of the medication is considered noncompliance is coercive and violates the client’s right to refuse treatment.

It also does not address the client’s reasons for refusing the medication or provide any information or education.

Choice C is wrong because informing the client that the medication is the same as taken at home is not enough to ensure that the client understands the purpose, benefits, and risks of the medication.

It also does not verify that the client is taking the medication correctly at home or that there are no changes in the dosage or frequency.

Choice D is wrong because insisting the client takes the prescribed medications is also coercive and violates the client’s right to refuse treatment.

It also does not respect the client’s autonomy, dignity, and preferences.

It may also cause harm to the client if they have an allergy, intolerance, or contraindication to the medication.

Advocacy for nursing stems from a philosophy of nursing in which nursing practice is the support of an individual to promote his or her own well-being, as understood by that individual. It is an ethic of practice that requires nurses to protect and uphold their patients’ rights, values, and interests.

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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?