The staff nurses have just received an inservice presentation about pressure Injury risk reduction in their clients. Which points should have been Included? (SELECT ALL THAT APPLY) Assess client's:
usual nutritional intake.
degree of physical activity.
skin exposure to moisture.
food and drug allergies.
ability to respond to pressure-related discomfort.
Correct Answer : A,B,C,E
A. Assessing usual nutritional intake helps identify potential risk factors for poor wound healing and pressure injury development.
B. Assessing the degree of physical activity helps determine the client's mobility level and risk for pressure injuries.
C. Assessing skin exposure to moisture helps identify potential areas of skin breakdown and pressure injury development.
D. While important, assessing food and drug allergies is not directly related to pressure injury risk reduction.
E. Assessing the client's ability to respond to pressure-related discomfort helps identify clients who may be at increased risk for pressure injuries due to decreased mobility or sensory deficits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Effective use of the incentive spirometer involves slow, sustained inhalation to raise the ball to the desired level and holding the breath for several seconds to fully expand the lungs.
B. Blowing into the mouthpiece is not the correct technique for using an incentive spirometer.
C. Beginning breathing with a rapid, forceful inspiration is not the correct technique for using an incentive spirometer.
D. Exhaling does not raise the ball in the incentive spirometer; it's inhalation that raises the ball to the desired level.
Correct Answer is A
Explanation
A. Intravenous (IV) medication delivery results in the most predictable onset because the medication is delivered directly into the bloodstream, bypassing absorption barriers, and has 100% bioavailability.
B. Subcutaneous and C. Transdermal routes may have variable absorption rates and bioavailability.
D. Oral medications may be affected by factors such as gastric emptying time and first-pass metabolism, resulting in less predictable onset and variable bioavailability.
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