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

Explanation

A. The most appropriate first action would be to increase the oxygen flowrate to improve the patient's oxygen saturation levels. This intervention directly addresses the hypoxemia and can help prevent further complications related to low oxygen levels in the blood.

B. Elevating the patient's head can help improve ventilation and oxygenation. By raising the head, the patient's airway may become more patent, allowing for better airflow and oxygen exchange in the lungs. However, this should follow oxygenation.

C. Suctioning the patient's mouth aims to remove any secretions or obstructions that may be compromising the airway and contributing to the low oxygen saturation. However, this should follow oxygenation.

D. This maneuver can be helpful if the airway is obstructed by the tongue or soft tissues, potentially improving ventilation and oxygenation. However, this should follow oxygenation.

A. Naproxen B. Amitriptyline C. Celecoxib D. Hydrocodone/Acetaminophen

Correct Answer is B

Explanation

B. Amitriptyline is a tricyclic antidepressant that is often used in low doses to treat neuropathic pain, including diabetic neuropathy. It can help relieve burning, shooting, or stabbing pain often associated with this condition.

A. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly used for relieving pain and inflammation associated with conditions like arthritis and musculoskeletal injuries. However, it is not typically used as a first-line treatment for neuropathic pain.

C. Celecoxib is a selective COX-2 inhibitor NSAID primarily used for its anti-inflammatory properties and pain relief in conditions like arthritis. While it may help with inflammation-associated pain, it is not specifically indicated for neuropathic pain.

D. While it may provide some relief, opioids are generally not recommended as first-line treatment for neuropathic pain due to their potential for dependence, tolerance, and other side effects.

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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 A

Explanation

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Correct Answer is B

Explanation

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