A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

A client who has protein calorie malnutrition

A client who has type1 diabetes mellitus and is hyperglycemic

A client who has right-sided heart failure and 4+ edema to the lower extremities

A client who has postoperative delirium

A client who is ambulatory following a cardiac catheterization 4 hr ago

Answer and Explanation

Correct Answer : A

A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.

B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.

C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.

D. A client with postoperative delirium is not necessarily at risk of delirium.

E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores

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Correct Answer is ["A","B","C","E"]

Explanation

A. Administering medication at the right time helps maintain therapeutic drug levels in the patient's system and ensures optimal treatment outcomes.

B. This means administering the correct medication to the patient as prescribed by the healthcare provider. It's crucial to verify the medication name, strength, and dosage form to prevent medication errors and adverse drug reactions.

C. It's essential to double-check the dose calculation and verify it against the prescription to prevent medication errors, especially with high-risk medications.

E. This means administering the medication to the correct patient. It's essential to verify the patient's identity using at least two patient identifiers (such as name and date of birth) before administering any medication to ensure it is being given to the intended recipient.

D. The color of medication is not typically considered one of the medication rights. While certain medications may have specific color coding for identification purposes, relying solely on color to identify a medication can be misleading and increase the risk of errors.

A. Keep the leg in a dependent position. B. Apply ice to the affected area. C. Remain on bedrest for the first 24 hr. D. Begin active range of motion.

Correct Answer is B

Explanation

B. Applying ice to the affected knee is a common postoperative instruction after arthroscopic knee surgery. Ice helps reduce swelling, inflammation, and pain in the surgical area. It is usually recommended to apply ice intermittently for short periods during the first 24 to 48 hours following surgery.

A. Keeping the leg in a dependent position, where it is hanging down, is not typically recommended following arthroscopic knee surgery.

C. Complete bedrest for the first 24 hours after arthroscopic knee surgery is not typically necessary or recommended. Early mobilization and gentle range of motion exercises are usually encouraged to prevent complications such as blood clots and joint stiffness.

D. These exercises help restore joint mobility, prevent stiffness, and promote healing of the surgical site. However, the timing and specific exercises should be guided by the surgeon's instructions and individual patient factors.

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A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements accurately describe the medication rights? (Select All that Apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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