A nurse is caring for a client who is scheduled for surgery.
Which of the following findings places the client at risk for delayed wound healing? Select all that apply.
Hyperlipidemia.
Diabetes mellitus.
Medication history.
Cholesterol level.
Prealbumin level.
Correct Answer : A,B,C,E
Choice A rationale:
Hyperlipidemia is a condition characterized by elevated levels of lipids (cholesterol and triglycerides) in the blood. High lipid levels are associated with atherosclerosis and impaired blood flow, which can hinder wound healing. Therefore, having hyperlipidemia places the client at risk for delayed wound healing.
Choice B rationale:
Diabetes mellitus is a chronic condition that can lead to impaired wound healing. High blood sugar levels in diabetes can damage blood vessels and nerves, reducing blood flow to wounds and impairing the body's ability to fight infection. Therefore, diabetes mellitus places the client at risk for delayed wound healing.
Choice C rationale:
The medication history is a crucial factor to consider in wound healing. Prednisolone, a corticosteroid, can suppress the immune system and impair the body's ability to heal wounds. Long-term use of prednisolone, as in this case (20 mg/day for the past 2 years), increases the risk of delayed wound healing. Therefore, the medication history places the client at risk for delayed wound healing.
Choice D rationale:
The cholesterol level, in this context, is less relevant to the immediate risk of delayed wound healing. While high cholesterol levels are a risk factor for atherosclerosis and cardiovascular diseases, they do not have a direct impact on wound healing. The other choices (A, B, and C) are more directly related to delayed wound healing in the context of this surgical patient.
Choice E rationale:
Prealbumin is a protein that reflects a person's nutritional status. A low prealbumin level indicates malnutrition or inadequate protein intake, which can hinder wound healing. Therefore, a low prealbumin level places the client at risk for delayed wound healing. Now, let's move on to the last question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Correct Answer is D
Explanation
Choice A rationale:
There are actually five rights of delegation: right task, right circumstance, right person, right direction/communication, and right supervision/evaluation. This statement is not accurate.
Choice B rationale:
It is not the duty of the delegatee to perform a task without asking questions. Effective delegation involves clear communication, including the opportunity for the delegatee to ask questions and seek clarification as needed.
Choice C rationale:
While the nurse manager plays a role in delegation, the responsibility for delegation does not solely rest on the nurse manager. Delegation is a shared responsibility among all nurses, and the person delegating the task must ensure it is appropriate and clear.
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