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 D
Explanation
Choice A rationale:
Purulent indicates pus, which is not described here.
Choice B rationale:
Infection usually presents with redness, swelling, and possibly pus, which is not described here.
Choice C rationale:
Debridement is the removal of dead tissue, not indicated by a pinkish-red bumpy area.
Choice D rationale:
A pinkish-red center area that looks bumpy indicates granulation tissue, which is a sign of healing.
Correct Answer is A
Explanation
Choice A rationale:
The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.
Choice B rationale:
The irrigant should be at room temperature, not chilled.
Choice C rationale:
The syringe should be held 1 inch (not 0.5 inch) from the wound.
Choice D rationale:
The wound should be flushed from the cleanest area to the most contaminated, not the other way around.
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