A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?
A client who has dementia and is incontinent of urine
A client who is 2 days postoperative following orthopedic surgery
A client who has a T-tube following an open cholecystectomy
A client who has had a recent myocardial infarction
The Correct Answer is A
Rationale:
A. A client who has dementia and is incontinent of urine: This client has multiple contributing factors, cognitive impairment limits repositioning and self-care, while urinary incontinence increases skin moisture and maceration, promoting skin breakdown and pressure injury formation.
B. A client who is 2 days postoperative following orthopedic surgery: Although this client may have limited mobility, they are typically on a monitored recovery path with interventions like repositioning, early ambulation, and pain management, reducing their overall risk.
C. A client who has a T-tube following an open cholecystectomy: This client is generally alert, mobile with assistance, and able to communicate needs, which lowers their risk of pressure injury compared to more dependent individuals.
D. A client who has had a recent myocardial infarction: This client may be monitored in bed rest initially, but cardiovascular stability and mobility often improve quickly with treatment, making their pressure injury risk moderate rather than the highest among the group.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Assist the client to ambulate: Ambulation is encouraged after a laparoscopic cholecystectomy to stimulate peristalsis and help relieve abdominal distention caused by retained gas from insufflation during the procedure. It promotes bowel movement and absorption of gas, improving comfort.
B. Prepare the client for a paracentesis: Paracentesis is used to remove fluid from the peritoneal cavity, typically in clients with ascites or severe fluid retention. Abdominal distention after this procedure is usually due to gas, not fluid.
C. Insert a rectal suppository: Suppositories may stimulate bowel movements but are not the first-line intervention for post-laparoscopic gas-related distention. Encouraging natural movement through ambulation is more effective and less invasive initially.
D. Place the client in the prone position: The prone position is not typically used for relieving abdominal distention. It may cause discomfort and does not aid in gas movement through the intestines as effectively as upright or walking positions.
Correct Answer is C
Explanation
Rationale:
A. Encourage the client to attend a group therapy session: This action does not immediately address the restraint status. The client’s calm and cooperative behavior should prompt reassessment of restraint necessity before introducing other interventions.
B. Continue to monitor the client every 15 min: Ongoing monitoring is important but it is not the priority once the client has de-escalated. If the behavior no longer warrants restraints, the nurse should act promptly to remove them to preserve the client’s rights and dignity.
C. Remove the restraints from the client: Restraints should be discontinued as soon as the client demonstrates self-control and no longer poses a risk to themselves or others. Keeping restraints on unnecessarily can lead to psychological harm, reduced mobility, and legal/ethical violations.
D. Offer the client PRN pain medication: Offering pain medication assumes the client is experiencing discomfort, but there is no indication of pain in the scenario. Medication is not the priority when behavioral signs point to de-escalation and restraint removal is warranted.
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