A nurse is caring for a client who is scheduled for surgery.
Exhibit 1
Medical History
0800:
Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus.
Mini Nutritional Assessment screening tool score of 7 points (0 to 14 points)
The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply
History of diabetes mellitus
Cholesterol level
Prealbumin level
History of hyperlipidemia
Mini Nutritional Assessment screening tool score
History of malnutrition
Correct Answer : A,C,E,F
A. History of diabetes mellitus: This is correct. Diabetes mellitus can lead to delayed wound healing due to various factors, including impaired circulation, neuropathy, and compromised immune function.
B. Cholesterol level: While abnormal cholesterol levels can impact cardiovascular health, they are not directly linked to delayed wound healing unless they are part of a broader metabolic disorder or condition that affects vascular health.
C. Prealbumin level: Prealbumin is a marker of nutritional status. Low prealbumin levels can indicate malnutrition, which is a risk factor for delayed wound healing.
D. History of hyperlipidemia: Hyperlipidemia refers to high levels of fats (lipids) in the blood, such as cholesterol and triglycerides. While hyperlipidemia is associated with cardiovascular risk, it is not a direct risk factor for delayed wound healing unless it is part of a broader metabolic syndrome or condition affecting vascular health.
E. Mini Nutritional Assessment screening tool score: This is correct. The Mini Nutritional Assessment (MNA) screening tool assesses nutritional status, and a low score indicates malnutrition or nutritional deficiencies, which can contribute to delayed wound healing.
F. History of malnutrition: This is correct. Malnutrition, whether due to inadequate intake, absorption issues, or other factors, is a significant risk factor for delayed wound healing as it affects the body's ability to repair tissues and fight infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Check the blood product's compatibility with the client's blood type: Before administering packed red blood cells (RBCs) or any blood product, it is crucial to ensure that the blood product matches the client's blood type and is compatible. This is done to prevent transfusion reactions and ensure safe administration.
B. Prime the client's primary IV tubing with lactated Ringer's: While it is important to prime the IV tubing with an appropriate solution before starting the transfusion, this action does not directly indicate prior to the start of the infusion.
C. Check that the client has a small gauge IV catheter in place: Having an appropriate size and functioning IV catheter in place is important for administering blood products, but this action does not specifically indicate prior to the start of the infusion.
D. Confirm the identity of the client with the blood bank technician: Confirming the client's identity is an essential step in ensuring that the correct blood product is administered to the correct client. However, this action is typically done before the blood product is prepared and delivered to the client's location, rather than immediately before starting the infusion.
Correct Answer is C
Explanation
A.Placing gauze under the flanges of the tracheostomy tube is not recommended because it can create a breeding ground for bacteria and increase the risk of infection.Pre-cut gauze pads should be used to avoid loose fibers from entering the stoma.
B.Full-strength hydrogen peroxide is too harsh and can cause skin irritation or damage. When performing tracheostomy care, the skin around the stoma should be cleaned with a mild saline solution.
C.A collar with hook-and-loop fastenersis commonly used to secure the tracheostomy tube in place. This collar should be snug enough to hold the tube securely but not too tight to cause discomfort or restrict airflow. The collar helps prevent accidental dislodgement of the tracheostomy tube, ensuring it remains properly positioned.
D.Sterile gloves should be worn when cleaning the inner cannula of the tracheostomy tube to minimize the risk of introducing pathogens.
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