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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Visual aids can be very helpful for patients with impaired speech. They can use pictures, written words, or devices to help express their thoughts2324.
Choice B rationale
Allowing extra time to communicate with the patient is crucial. It can reduce frustration and improve the effectiveness of communication2324.
Choice C rationale
Completing sentences for the patient can be disrespectful and may not accurately convey the patient’s thoughts2324.
Choice D rationale
Asking open-ended questions can be challenging for a person with impaired speech. It’s better to ask yes/no questions or use other communication strategies2324.
Correct Answer is C
Explanation
Choice A rationale
Sterile gloves are not necessary when checking a patient’s pulse. They are typically used for procedures that require aseptic technique, such as wound dressing changes or insertion of a central venous catheter.
Choice B rationale
Protective eyewear is used to protect the healthcare provider from splashes or sprays of blood, body fluids, secretions, or excretions. It is not necessary when checking a patient’s pulse.
Choice C rationale
Clean gloves should be worn when touching blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. This includes when caring for a patient with MRSA in an abdominal wound.
Choice D rationale
An N95 respirator mask is used to protect the healthcare provider from airborne pathogens, such as tuberculosis. It is not necessary when checking a patient’s pulse.
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