A nurse is reviewing the medical record of a client who has a stage 2 pressure injury. The nurse should identify that which of the following findings can impair the client's ability to heal?

Elevated vitamin K levels

Zinc deficiency

Constipation

Acid reflux

Answer and Explanation

The Correct Answer is B

A. Elevated vitamin K levels: While excessive levels of Vitamin K can sometimes increase the risk of bleeding, it does not directly hinder the body’s ability to heal pressure injuries. Healing of wounds is more dependent on factors like protein and collagen synthesis, which are affected by zinc levels rather than vitamin K.
B. Zinc deficiency: Zinc plays a crucial role in wound healing by supporting cell growth, collagen formation, and immune function. A deficiency in zinc impairs the synthesis of collagen, which is necessary for the healing of pressure injuries. It also weakens the immune system, increasing the risk of infection and delaying the healing process.
C. Constipation: While constipation can cause discomfort and lead to additional complications, such as straining or increased intra-abdominal pressure, it does not directly affect the healing process of the skin or tissue at the site of a pressure injury.
D. Acid reflux: Acid reflux, or gastroesophageal reflux disease (GERD), primarily affects the digestive system and is not directly related to wound healing. While chronic acid reflux can cause discomfort and complications like esophageal damage, it does not impact the body’s ability to heal a pressure injury.

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Correct Answer is C

Explanation

A. Clear-colored urine: Clear-colored urine typically indicates adequate hydration or even overhydration. In Clostridium difficile, where the client may be experiencing profuse diarrhea, clear urine would not align with fluid volume deficit. This finding suggests the kidneys are excreting diluted urine, which is not consistent with dehydration.
B. Decreased urine specific gravity: A decreased urine specific gravity reflects dilute urine and usually points to overhydration or an inability to concentrate urine. In a client with C. difficile and likely diarrhea-related fluid loss, the expected finding would be a concentrated urine with increased specific gravity, not decreased.
C. Increased hematocrit: An increased hematocrit indicates hemoconcentration, which occurs when plasma volume is reduced due to fluid loss. In the setting of Clostridium difficile infection, where fluid is lost rapidly through diarrhea, this rise in hematocrit is a classic marker of fluid volume deficit. It reflects the relative increase in red blood cells due to a lower plasma volume.
D. Hypertension: Hypertension is more commonly associated with fluid volume excess or other cardiovascular conditions. In cases of fluid volume deficit, hypotension or orthostatic hypotension is more expected due to decreased circulating blood volume. Therefore, high blood pressure would not support the diagnosis of dehydration in this context.

Correct Answer is ["236"]

Explanation

Identify the calorie content per gram of each macronutrient.

Protein: 4 calories/gram

Fat: 9 calories/gram

Carbohydrates: 4 calories/gram

Calculate the calories from protein.

Calories from protein = 2 g × 4 calories/gram

= 8 calories.

Calculate the calories from fat.

Calories from fat = 12 g × 9 calories/gram

= 108 calories.

Calculate the calories from carbohydrates.

Calories from carbohydrates = 30 g × 4 calories/gram

= 120 calories.

Calculate the total calories in the cookie.

Total calories = Calories from protein + Calories from fat + Calories from carbohydrates

= 8 calories + 108 calories + 120 calories

= 236 calories.

Rounded to the nearest whole number: 236.

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A nurse is reviewing the medical record of a client who has a stage 2 pressure injury. The nurse should identify that which of the following findings can impair the client's ability to heal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory findings of a client who has Clostridium difficile. Which of the following findings should indicate to the nurse that the client is experiencing a fluid volume deficit?

Correct Answer is C

Explanation

A nurse is providing education to adolescents about healthy food choices. A cookie has 2 g of protein, 12 g of fat, and 30 g of carbohydrates. How many calories does the cookie contain? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["236"]

Explanation

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