Author Question: A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic ... (Read 81 times)

Bernana · **on:** Jul 22, 2018

A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?

a. Administer pain medication every 4 hours as needed.
b. Turn the patient every 2 hours, even hours.
c. Monitor vital signs, especially rhythm.
d. Keep the bed side rails up at all times.

Question 2

Which action will the nurse take after the plan of care for a patient is developed?

a. Place the original copy in the chart, so it cannot be tampered with or revised.
b. Communicate the plan to all health care professionals involved in the patient's care.
c. File the plan of care in the administration office for legal examination.
d. Send the plan of care to quality assurance for review.

strudel15 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: B
The most appropriate intervention for the diagnosis of Impaired skin integrity is to turn the patient. Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. The other options do not directly address the shearing forces. The patient may need pain medication, but Acute pain would be another nursing diagnosis. Monitoring vital signs does not have when or how often these should be done. Keeping the side rails up addresses safety, not skin integrity.

Answer to Question 2

ANS: B
Setting realistic goals and outcomes often means you must communicate these goals and outcomes to caregivers in other settings who will assume responsibility for patient care. The plan of care communicates nursing care priorities to nurses and other health care professionals. Know also that a plan of care is dynamic and changes as the patient's needs change. All health care professionals involved in the patient's care need to be informed of the plan of care. The plan of care is not sent to the administrative office or quality assurance office.