A nurse is collecting data on a client.
Which of the following findings increase the client's risk of a pressure injury?
BMI of 20.
Peripheral neuropathy.
Immobility.
Hypoperfusion.
Prealbumin level of 16 mg/dL.
Correct Answer : B,C,D
D.
Choice A rationale:
A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of pressure injuries.
Choice B rationale:
Peripheral neuropathy can lead to decreased sensation, increasing the risk of pressure injuries as the person may not feel discomfort from prolonged pressure.
Choice C rationale:
Immobility is a major risk factor for pressure injuries as it increases the duration of pressure on certain areas of the body.
Choice D rationale:
Hypoperfusion, or reduced blood flow, can lead to tissue damage and increase the risk of pressure injuries.
Choice E rationale:
A prealbumin level of 16 mg/dL is within the normal range (15-36 mg/dL), so it does not increase the risk of pressure injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Abdominal pads are not designed to minimize pain during dressing changes.
Choice B rationale:
Hydrogel dressings are known to minimize pain during dressing changes.
Choice C rationale:
Wet-to-dry dressings can cause discomfort during dressing changes.
Choice D rationale:
Dry gauze can stick to the wound bed and cause pain during dressing changes.
Correct Answer is D
Explanation
Choice A rationale:
Sharp debridement involves the use of a sharp instrument or heat to remove dead tissue, which is not achieved with a hydrocolloid dressing.
Choice B rationale:
Chemical debridement involves the use of chemicals to remove dead tissue, which is not the function of a hydrocolloid dressing.
Choice C rationale:
Enzymatic debridement involves the use of enzymes to soften and remove dead tissue, which is not the function of a hydrocolloid dressing.
Choice D rationale:
Autolytic debridement uses the body’s own enzymes and moisture to soften and remove dead tissue. A hydrocolloid dressing helps maintain a moist wound environment, promoting autolytic debridement.
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