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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 C

Explanation

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

A. Document your findings. B. Assess the patient for any complaints or problems in the wound area. C. Check the setting on the NPWT unit. D. Observe the dressing area when assessing vital signs.

Correct Answer is B

Explanation

Choice A rationale:

Documentation is important but not the first priority.

Choice B rationale:

Assessing the patient for any complaints or problems in the wound area is the first priority in NPWT treatment.

Choice C rationale:

Checking the setting on the NPWT unit is important but comes after assessing the patient.

Choice D rationale:

Observing the dressing area when assessing vital signs is part of the assessment process but not the first priority.

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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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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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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?