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. A thrill is a palpable vibration or buzzing sensation felt over the graft site, caused by turbulent blood flow. In the context of an arteriovenous graft, a palpable thrill is typically considered a positive finding, indicating adequate circulation through the graft. It suggests that blood is flowing smoothly from the arterial to the venous side of the graft.
A. The presence of a bruit is typically considered a positive finding, indicating adequate blood flow through the graft. Therefore, the absence of a bruit may indicate inadequate circulation or a potential complication such as graft occlusion or stenosis.
B. Normal blood pressure is not a specific indicator of the adequacy of circulation through an arteriovenous graft.
C. A dilated appearance of the graft may suggest venous hypertension or increased pressure within the graft. While this could indicate adequate blood flow, it may also suggest problems such as venous stenosis or thrombosis, which can impede circulation through the graft.

A. "I will ensure their neck is flexed backwards when they're lying on their stomach." B. "I will support their feet with a rolled pillow when they are lying on their back." C. "I will rest their heels on the mattress when they are sitting up in bed." D. "I will use a thick pillow under their head to support the neck."

Correct Answer is B

Explanation

B. Supporting the feet with a rolled pillow helps prevent foot drop (a common issue in hemiplegia). It maintains the ankle in a neutral position, preventing contractures.
A. When lying on the stomach (prone position), the neck should be neutral (neither flexed nor extended). Flexing the neck backward can strain the cervical spine and compromise airway alignment.
C. For a client with right-sided hemiplegia, the affected leg (right leg) should be supported to prevent foot drop.
D. A thick pillow under the head can cause neck hyperextension.
The head should be supported with a small, firm pillow to maintain a neutral neck position.

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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 has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

Correct Answer is D

Explanation

A nurse is teaching about safe positioning with the caregiver of a client who has right-sided hemiplegia following a stroke. Which of the following statements by the caregiver indicates an understanding of the teaching?

Correct Answer is B

Explanation

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