A client has recently arrived in the ED. Upon assessment, which observation by the nurse will indicate the client is at risk for pressure injury formation?
The client is working daily with PT and OT.
The clients eating 75-100% of their daily meals.
The client is immobile and is currently bedbound.
The client appears to have a capillary refill of less than 2 seconds.
The Correct Answer is C
A. The client is working daily with PT and OT: Regular participation in physical and occupational therapy indicates mobility and activity, which lowers the likelihood of pressure injury development.
B. The client is eating 75–100% of their daily meals: Adequate oral intake supports nutrition and tissue integrity, reducing pressure ulcer risk.
C. The client is immobile and is currently bedbound: Prolonged immobility and being bedbound increase pressure over bony prominences and are strong risk factors for pressure injury formation.
D. The client appears to have a capillary refill of less than 2 seconds: Capillary refill under 2 seconds suggests adequate peripheral perfusion, which does not by itself indicate increased risk for pressure injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client is working daily with PT and OT: Regular participation in physical and occupational therapy indicates mobility and activity, which lowers the likelihood of pressure injury development.
B. The client is eating 75–100% of their daily meals: Adequate oral intake supports nutrition and tissue integrity, reducing pressure ulcer risk.
C. The client is immobile and is currently bedbound: Prolonged immobility and being bedbound increase pressure over bony prominences and are strong risk factors for pressure injury formation.
D. The client appears to have a capillary refill of less than 2 seconds: Capillary refill under 2 seconds suggests adequate peripheral perfusion, which does not by itself indicate increased risk for pressure injuries.
Correct Answer is A
Explanation
A. PO: Abbreviation from Latin per os, meaning “by mouth,” used to indicate oral administration of a medication.
B. ACHS: Stands for “before meals and at bedtime” (ante cibum, hora somni) and refers to timing relative to meals, not the route of administration.
C. PRN: Means “as needed” (pro re nata) and indicates dosing frequency/condition, not the route.
D. NPO: Means “nothing by mouth” (nil per os) and indicates the patient should not take anything orally, so it does not instruct oral administration.
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