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 D

Explanation

Choice A rationale:
High lipase is not a typical laboratory finding related to overusing prescribed diuretics and a sodium level of 127 mEq/L. Lipase is an enzyme involved in lipid digestion and is more relevant in assessing pancreatic function.
Choice B rationale:
High creatine kinase-MB (CK-MB) is not associated with overusing prescribed diuretics or hyponatremia (low sodium level). CK-MB is a specific marker for myocardial damage and is usually elevated in conditions like myocardial infarction.
Choice C rationale:
Low hemoglobin is not directly related to overusing prescribed diuretics and a sodium level of 127 mEq/L. Low hemoglobin may indicate anemia or other hematological issues but this is not a typical finding in this scenario.
Choice D rationale:
The correct answer is low urine specific gravity. Overusing diuretics can lead to excessive urination, causing the urine to become more dilute with lower specific gravity. A low urine specific gravity indicates decreased urine concentration and can be a sign of fluid and electrolyte imbalances, including hyponatremia.

A. PaO2 86 mm Hg. B. pH 7.4. C. HCO3 16 mEq/L. D. PaCO2 58 mm Hg.

Correct Answer is D

Explanation

Choice A rationale:
A PaO2 value of 86 mm Hg is within the normal range (80-100 mm Hg) and does not indicate respiratory acidosis. PaO2 measures the partial pressure of oxygen in arterial blood.
Choice B rationale:
A pH of 7.4 is within the normal range (7.35-7.45) and does not indicate respiratory acidosis. The pH reflects the acidity or alkalinity of the blood.
Choice C rationale:
An HCO3 (bicarbonate) level of 16 mEq/L is within the normal range (22-28 mEq/L) and does not indicate respiratory acidosis. HCO3 is a measure of the metabolic component of the body's acid-base balance.
Choice D rationale:
This is the correct choice. A PaCO2 value of 58 mm Hg is elevated and indicates respiratory acidosis. PaCO2 measures the partial pressure of carbon dioxide in arterial blood, and an elevated value suggests the presence of excess carbon dioxide, leading to acidosis.

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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?

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Naxlex Comprehensive Predictor Exams

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