A nurse is assessing the skin of an immobilized patient. What will the nurse do?
a. Assess the skin every 4 hours.
b. Limit the amount of fluid intake.
c. Use a standardized tool such as the Braden Scale.
d. Have special times for inspection so as to not interrupt routine care.
ANS: C
Consistently use a standardized tool, such as the Braden Scale. This identifies patients with a high risk for impaired skin integrity. Skin assessment can be as often as every hour. Limiting fluids can lead to dehydration, increasing skin breakdown. Observe the skin often during routine care.
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