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 C

Explanation

C. Maintaining immobilization and alignment of the fractured bone is essential for allowing the bone to heal properly. Immobilization prevents further injury and displacement of the fracture fragments, while proper alignment ensures optimal bone healing and functional outcomes.

A. Optimal nutrition and hydration may not be the highest priority compared to other interventions that directly address the fracture management and functional healing.

B. Providing relief from pain and discomfort is crucial for the client's comfort and well-being, but it may not be the highest priority in achieving functional healing.

D. Promoting independence in activities of daily living is important for the client's overall well-being and quality of life, but it may not be the highest priority immediately after a fracture.

A. "You will need to remove all jewelry before the test." B. "You will need to fast for 12 hours before the test." C. "You will need to empty your bladder before the test." D. "You will need to lie flat for 4 hours following the test."

Correct Answer is A

Explanation

A. Metal objects, including jewelry, can interfere with the DXA scan and affect the quality of the images. Therefore, it is important for the client to remove all jewelry and metal objects before the test to ensure accurate results.

B. Fasting is not typically required for a dual-energy x-ray absorptiometry (DXA) scan. DXA scans are non- invasive and do not involve the administration of any substances that would necessitate fasting.

C. This instruction is not specifically required for a DXA scan. However, it is generally a good practice for clients to empty their bladder before any imaging test to ensure comfort during the procedure.

D. This instruction is not accurate for a DXA scan. DXA scans are typically quick procedures that do not require the client to lie flat for an extended period afterward. Clients can resume their normal activities immediately following the scan without any restrictions.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

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