A nurse is caring for an older adult patient with chronic obstructive pulmonary disease. The patient always remains in a sitting position to help them breathe more easily. Based on this information, what area on the patient's body should be frequently assessed for skin breakdown?

Elbows and behind the ears

Coccyx and back of the skull

Heels and trochanter

Sacrum and ischium

Answer and Explanation

The Correct Answer is D

A. Elbows and behind the ears: These areas are not primary pressure points in a seated position.

B. Coccyx and back of the skull: The coccyx is a pressure point when lying down, but this patient is sitting most of the time.

C. Heels and trochanter: Heels are at risk in supine patients, but this patient is primarily sitting.

D. Sacrum and ischium: The sacrum and ischium (sit bones) bear the most pressure in a seated position, making them highly vulnerable to skin breakdown.

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Correct Answer is A

Explanation

A. Placing an indwelling urinary catheter: Indwelling urinary catheters are a leading cause of catheter-associated urinary tract infections (CAUTIs), which are common healthcare-associated infections.

B. Administering medications through an NG tube: While NG tubes can introduce bacteria, they are not as high-risk as urinary catheters, which provide a direct route for infection.

C. Changing a sacral wound dressing: While wounds can become infected, proper wound care techniques minimize risk. Urinary catheters pose a greater risk due to prolonged exposure to bacteria.

D. Replacing an ostomy appliance: While maintaining hygiene is important, ostomy appliances are not a major source of healthcare-associated infections compared to urinary catheters.

A. Avoid using your fingers to open the mouth. B. Apply moisturizer to the oral mucosa and lips. C. Brush the teeth with a soft bristled toothbrush D. Use a toothbrush with a suction attachment

Correct Answer is D

Explanation

A. Avoid using your fingers to open the mouth: While this is a safety measure to prevent injury, it is not the most important intervention.

B. Apply moisturizer to the oral mucosa and lips: While this is beneficial for comfort, preventing aspiration and maintaining airway patency are higher priorities.

C. Brush the teeth with a soft-bristled toothbrush: Oral hygiene is important, but the highest priority is preventing aspiration.

D. Use a toothbrush with a suction attachment: Suction prevents the accumulation of oral secretions, reducing the risk of aspiration pneumonia in a sedated patient.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

A nurse is caring for an older adult patient with chronic obstructive pulmonary disease. The patient always remains in a sitting position to help them breathe more easily. Based on this information, what area on the patient's body should be frequently assessed for skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The following procedures have been ordered and implemented for a hospitalized patient. Which procedure carries the greatest risk for a healthcare-associated infection?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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