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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.

Answer and Explanation

Correct Answer : B,C,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.

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Correct Answer is A

Explanation

Choice A rationale:

The side-lying position allows gravity to assist in wound irrigation and prevent pooling of the solution.

Choice B rationale:

High-Fowler’s position is not ideal for abdominal wound irrigation as it can lead to pooling of the solution.

Choice C rationale:

In the supine position, the solution can pool around the wound and not effectively irrigate it.

Choice D rationale:

The dorsal recumbent position is not ideal as it can also lead to pooling of the solution.

A. The patient has to be repositioned for the bed to be changed. B. Shearing is more likely from wet sheets. C. The moisture creates an environment suitable for the growth of microorganisms in a wound. D. Greater pressure is exerted by a wet bed.

Correct Answer is C

Explanation

Choice A rationale:

Repositioning the patient for bed changing does not directly contribute to skin breakdown or infection.

Choice B rationale:

While shearing can cause skin breakdown, it is not directly related to incontinence or wet sheets.

Choice C rationale:

Moisture from incontinence can create an environment suitable for the growth of microorganisms in a wound, leading to infection and skin breakdown.

Choice D rationale:

A wet bed does not exert greater pressure on the patient’s skin.

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A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

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Naxlex Comprehensive Predictor Exams

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