A nurse is reviewing the medical record of a client who had abdominal surgery 2 days ago. The nurse should identify that which of the following findings indicates the client is at risk for delayed wound healing?

Pain level of 1 on a scale of 0 to 10

Oxygen saturation of 92% on room air

Albumin level of 2.5 g/dL

Body mass index of 22

Answer and Explanation

The Correct Answer is C

Choice A reason: A pain level of 1 on a 0-10 scale indicates well-controlled pain, which does not directly impair wound healing. Adequate pain management supports mobility and recovery, reducing stress responses that could delay healing. This finding is not a risk factor for delayed wound healing in post-surgical clients.
Choice B reason: An oxygen saturation of 92% on room air is slightly low but not critically hypoxic. Wound healing requires adequate oxygenation, but levels above 90% are generally sufficient for tissue repair. This finding alone does not significantly indicate a risk for delayed wound healing compared to nutritional deficits.
Choice C reason: An albumin level of 2.5 g/dL (normal: 3.5-5.0 g/dL) indicates malnutrition, a major risk for delayed wound healing. Albumin is essential for tissue repair, collagen synthesis, and immune function. Low levels impair fibroblast activity and wound strength, increasing infection risk and slowing recovery in post-surgical clients.
Choice D reason: A body mass index of 22 is within the normal range (18.5-24.9) and does not indicate malnutrition or obesity, both of which can impair wound healing. Normal BMI supports adequate nutritional status for tissue repair, making this finding not a risk factor for delayed wound healing.

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Correct Answer is A

Explanation

Choice A reason: Using a cane provides stability and reduces fall risk for clients with multiple sclerosis, who often experience muscle weakness or balance issues. This assistive device promotes safe mobility, aligning with evidence-based safety strategies, making it the correct precaution for home care.
Choice B reason: Walking with feet close together decreases stability, increasing fall risk in multiple sclerosis due to impaired coordination. A wider stance is recommended for balance, making this precaution incorrect and potentially dangerous for the client’s safety.
Choice C reason: Avoiding orthotics is not advisable, as they can support mobility and prevent foot drop in multiple sclerosis. Orthotics improve safety and function, so discouraging their use is counterproductive, making this an incorrect recommendation for home safety.
Choice D reason: A rigorous range-of-motion exercise plan may cause fatigue or injury in multiple sclerosis, where moderated exercise is preferred. Overexertion exacerbates symptoms, so this plan is unsafe and inappropriate, making it incorrect for promoting client safety.

A. Offer your infant the breast when he shows signs of hunger. B. Limit the time your infant feeds to 10 minutes on each breast. C. Begin each feeding with the same breast. D. Ensure the infant feeds every 6 hours.

Correct Answer is A

Explanation

Choice A reason: Offering the breast at hunger cues, like rooting, supports demand feeding, regulating milk supply via prolactin. This ensures adequate nutrition and bonding, critical for infant growth and lactation success, aligning with evidence-based breastfeeding practices for optimal maternal-infant outcomes.
Choice B reason: Limiting feeding to 10 minutes per breast restricts hindmilk intake, rich in fat, reducing nutrition and milk supply. Fixed timing disrupts prolactin-driven lactation, risking inadequate weight gain, contrary to breastfeeding guidelines recommending unrestricted feeding based on infant cues.
Choice C reason: Starting each feeding with the same breast risks unbalanced milk production and engorgement. Alternating breasts ensures even stimulation and emptying, maintaining supply and preventing complications, making this incorrect for supporting effective breastfeeding practices in new parents.
Choice D reason: Feeding every 6 hours is too infrequent for newborns, needing feeds every 2-3 hours to meet nutritional demands and stimulate milk production. Fixed schedules ignore hunger cues, risking dehydration or poor growth, contradicting evidence-based breastfeeding recommendations for infants.

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A nurse is reviewing the medical record of a client who had abdominal surgery 2 days ago. The nurse should identify that which of the following findings indicates the client is at risk for delayed wound healing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing home care with a client who has multiple sclerosis. Which of the following precautions should the nurse recommend to promote client safety?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a new parent about breastfeeding her infant. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?

A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

A nurse is planning care for a client who has reduced visual sensory perception. Which of the following interventions should the nurse include in the plan of care?

A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that the client is at risk for developing a surgical wound infection?

A nurse is preparing to assess a client for a pulse deficit. Which of the following actions should the nurse plan to take?

A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet?

A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan of care?

A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?