A nurse is caring for several clients who are at risk of developing a pressure injury. Which of the following clients is most at risk?

A 23-year-old client who is in skeletal traction.

A 67-year-old client who has coronary artery disease.

A 32-year-old client who has a spinal cord injury.

A 55-year-old client who has emphysema.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A 23-year-old client in skeletal traction may be at risk of pressure injuries, but being young and presumably healthier than the other options, this client may have a lower risk compared to the other choices.

Choice B rationale:

A 67-year-old client with coronary artery disease may be at risk of pressure injuries, especially if the client has limited mobility or is bedridden. However, coronary artery disease alone does not significantly increase the risk of pressure injuries.

Choice C rationale:

A 32-year-old client with a spinal cord injury is most at risk of developing a pressure injury. Spinal cord injuries often result in paralysis or limited mobility, leading to prolonged pressure on specific areas of the body, which can cause pressure ulcers.

Choice D rationale:

A 55-year-old client with emphysema may have compromised lung function, but this alone does not significantly increase the risk of pressure injuries. Pressure injuries are primarily related to immobility and pressure on specific body areas.

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Correct Answer is A

Explanation

Choice A rationale:

Administering phenytoin IV no faster than 100 mg/min is crucial to prevent adverse effects such as cardiovascular collapse or severe hypotension. Rapid administration of phenytoin can cause cardiac arrhythmias and should be avoided.

Choice B rationale:

Monitoring plasma phenytoin levels to establish the therapeutic range is a necessary action in managing the client's seizure disorder, but it does not pertain to the specific administration of phenytoin via intermittent bolus.

Choice C rationale:

Adding the medication to the existing IV solution is not appropriate for phenytoin administration. Phenytoin should be administered separately and not mixed with other IV solutions to maintain its stability and prevent interactions.

Choice D rationale:

Monitoring the client for hypertension is not directly related to the administration of phenytoin via intermittent bolus. Hypertension is not a common adverse effect of this medication. However, blood pressure should be monitored as part of routine care for any client on antiepileptic therapy.

A. Elevated WBC Count. B. Elevated amylase level. C. Rebound tenderness. D. Ascites. E. Anorexia.

Correct Answer is ["A","C","E"]

Explanation

Choice A rationale:

An elevated white blood cell (WBC) count is an expected manifestation in a client with suspected appendicitis. Inflammation in the appendix leads to an immune response, causing an increase in WBC count.

Choice B rationale:

Elevated amylase level is not typically associated with appendicitis. Elevated amylase is more commonly seen in pancreatitis, not appendicitis.

Choice C rationale:

Rebound tenderness, which refers to increased pain when pressure is released rather than applied, is a classic symptom of appendicitis. The nurse should expect to find rebound tenderness during the abdominal assessment.

Choice D rationale:

Ascites are not a common manifestation of appendicitis. Ascites is the accumulation of fluid in the abdominal cavity and are more commonly seen in liver cirrhosis and certain other conditions, but not in appendicitis.

Choice E rationale:

Anorexia, or loss of appetite, can be seen in clients with appendicitis due to the inflammation and discomfort in the abdominal region.

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A nurse is caring for several clients who are at risk of developing a pressure injury. Which of the following clients is most at risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to administer phenytoin IV via intermittent bolus to a client who has a seizure disorder and is receiving a continuous IV infusion of dextrose 5% in water (D5W). Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect?(Select all that apply.).

Correct Answer is ["A","C","E"]

Explanation

A nurse is reviewing the ABGs of a client who has pneumonia. The nurse should identify which of the following findings is an indication of respiratory acidosis.

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