A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown?

Receiving bronchodilator medication

Weight loss of 2.8 kg (6.2 b)

Hemoglobin 17 g/dl (12 to 16 g/dL)

Wearing an oxygen device

Answer and Explanation

The Correct Answer is B

Indicates an increased risk of skin breakdown. This is because significant weight loss can lead to muscle wasting and reduced subcutaneous tissue, making the skin more vulnerable.

Bronchodilators, hemoglobin level and oxygen device do not relate directly to skin breakdown

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Correct Answer is D

Explanation

D. The primary purpose of maintaining an elastic bandage around the residual limb after a below-the- knee amputation is to provide compression and support, which helps minimize swelling (edema) of the residual limb. By reducing edema, the elastic bandage can promote proper wound healing, improve comfort, and facilitate the fitting of prosthetic devices in the future.
A. While maintaining proper wound care and hygiene can help prevent wound infections, an elastic bandage around the residual limb of a below-the-knee amputation primarily serves other purposes, such as providing compression and support, rather than directly preventing wound infections.
B. The purpose of an elastic bandage is not to conceal the surgical site. It is used primarily for compression, support, and minimizing swelling of the residual limb.
C. While an elastic bandage may help provide some pressure and support to the surgical site, its primary purpose is not to prevent sutures from loosening.

A. Sore throat B. SaO, 92% C. Stridor D. Rhonchi

Correct Answer is C

Explanation

C. Stridor is a high-pitched, crowing sound that occurs during inspiration and indicates upper airway obstruction. Stridor following extubation is a concerning finding and requires immediate intervention to ensure adequate airway patency and prevent respiratory compromise. The nurse should notify the healthcare provider immediately and be prepared to provide interventions such as airway suctioning, supplemental oxygen, or reintubation if necessary.

A. While a sore throat is a common complaint after extubation due to irritation from the endotracheal tube, it does not typically require immediate intervention unless it is severe or accompanied by other concerning symptoms. The nurse should provide comfort measures and monitor for worsening symptoms.
B. An SPO2 of 92% is within normal rage and requires no immediate intervention.
D. While rhonchi may require intervention, they are not typically as immediately concerning as stridor, which indicates upper airway obstruction.

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A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?

Correct Answer is D

Explanation

A nurse is assessing a client following extubation from a Ventilator. For which of the following findings should the nurse intervene immediately?

Correct Answer is C

Explanation

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