Author Question: The nurse is caring for a surgical patient. Which intervention is most important for the nurse to ... (Read 62 times)

renzo156 · **on:** Jul 22, 2018

The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility?

a. Explain the risks of immobility to the patient.
b. Turn the patient every 3 hours while in bed.
c. Encourage the patient to sit up in the chair.
d. Provide analgesic medication as ordered.

Question 2

The nurse is completing a skin risk assessment using the Braden Scale.

The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?
a. 15
b. 17
c. 20
d. 23

chem1s3 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: D
Maintaining adequate pain control (providing analgesic medications) and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. Although sitting in the chair is beneficial, it does not increase mobility or provide pain control. Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours and, again, does not influence the patient's ability to increase mobility.

Answer to Question 2

ANS: C
With use of the Braden Scale, the total score is a 20. The patient receives 3 for slight sensory perception impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear.