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","C","D"]

Explanation

A. Assessing the temperature of the affected extremity is important because changes in temperature could indicate circulation problems, which are a concern with traction. Assessing temperature helps in detecting any potential issues early on.

C. Skin integrity is crucial as traction can put pressure on the skin, potentially leading to pressure ulcers or skin breakdown. Regular examination helps in detecting any signs of skin irritation or breakdown early so that appropriate interventions can be initiated.

D. Traction can sometimes impede circulation to the affected limb, leading to complications such as compartment syndrome. Monitoring peripheral pulses helps in detecting any circulation problems promptly.

B. Adjusting the prescribed weights is not typically within the nurse's scope of practice, as the weights are determined by the physician and should not be altered without specific orders.

E. Positioning the weights against the foot of the bed is incorrect; they should hang freely to maintain effective traction.

A. Osteomyelitis B. Acute compartment syndrome C. Fat embolism syndrome D. Pulmonary embolism

Correct Answer is B

Explanation

B. Acute compartment syndrome occurs when increased pressure within a muscle compartment compromises circulation to the muscles and nerves within that compartment. Fractures, especially those accompanied by significant soft tissue injury or bleeding, can lead to compartment syndrome.

A Osteomyelitis is an infection of the bone that can occur as a complication of fractures, particularly if the fracture is open (the bone breaks through the skin). This occurs in the later courses of an infection.

C Fat embolism syndrome occurs when fat globules from fractured bones enter the bloodstream and become lodged in small blood vessels in organs such as the lungs, brain, and skin. Increasing edema is not an early sign of fat embolism.

D Pulmonary embolism (PE) is a serious condition where a blood clot travels to the lungs and blocks blood flow. While fractures, especially long bone fractures, can increase the risk of developing blood clots, increasing edema in the fractured limb is not typically an early sign of pulmonary embolism.

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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

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is B

Explanation

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