A nurse is caring for a 68-year-old male client who was admitted to a rehabilitation unit following a repair of a right hip fracture. The client has limited mobility and requires assistance to turn and transfer out of bed. It’s Day 4, 0700hrs.
The client is at greatest risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
The client is at greatest risk for developing a Pressure ulcer due to Limited mobility.
The client’s limited mobility and the need for assistance to turn and transfer out of bed increases the risk of pressure ulcers. Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People most at risk of pressure ulcers are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Discarding any residual gastric contents before administering the tube feeding is not necessary and could lead to unnecessary loss of nutrients and electrolytes.
Choice B rationale
Positioning the patient in a low Fowler’s position is not the optimal position for administering a tube feeding. The patient should be in an upright position to reduce the risk of aspiration.
Choice C rationale
Testing the pH of the gastric aspirate is an important step before administering a tube feeding. This helps to verify that the feeding tube is in the stomach and not in the lungs.
Choice D rationale
Warming the feeding solution to body temperature is not necessary and could potentially lead to bacterial growth in the feeding solution.
Correct Answer is D
Explanation
Choice A rationale
Increased collagen is not a factor that would lead to a pressure injury in a client with impaired mobility. Collagen is a protein that helps in the formation of skin and other connective tissues.
Choice B rationale
Decreased serum calcium is not directly related to the development of pressure injuries. While calcium is important for bone health and muscle function, it does not play a direct role in skin integrity.
Choice C rationale
Increased muscle mass is not a risk factor for pressure injuries. In fact, good muscle mass can help distribute pressure more evenly and potentially reduce the risk of pressure injuries.
Choice D rationale
Decreased circulation is a major risk factor for the development of pressure injuries. When blood flow to an area of the body is reduced, the tissues in that area can become deprived of oxygen and nutrients, leading to cell death and the formation of pressure injuries.
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