A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor for pressure ulcer?

Male

Immobility

Adequate hydration

Anemia

Answer and Explanation

The Correct Answer is B

A. Being male is not a significant risk factor for developing pressure ulcers. Pressure ulcers are more related to factors like immobility, nutritional status, and circulation.

B. Immobility is a major risk factor for pressure ulcer development. Clients who are immobile or confined to bed, especially for prolonged periods, are at higher risk due to continuous pressure on certain body areas, leading to skin breakdown.

C. Adequate hydration helps maintain skin integrity and is not a risk factor for pressure ulcers. Dehydration, rather than adequate hydration, can contribute to skin breakdown.

D. Anemia can impact tissue oxygenation, but immobility is a more direct risk factor for pressure ulcer development. Although anemia can slow healing, immobility leads to constant pressure on the skin, causing tissue breakdown and ulceration.

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

Explanation

A. A quadriplegic client is at high risk for pressure injuries due to immobility and lack of sensation, which can lead to prolonged pressure on skin and tissues.

B. A Braden Scale score of 7 indicates severe risk for pressure injuries. The lower the Braden score, the higher the risk, with scores less than 9 signifying very high risk.

C. A client with controlled diabetes who is ambulating frequently is not at high risk for pressure injuries because mobility reduces the risk of sustained pressure.

D. A BMI of 13.6 indicates severe underweight status, and incontinence of stool increases moisture, both of which elevate the risk of pressure injuries. Additionally, the splint on the leg may create pressure points.

A. Assist the client to the bathroom every 2 hr. B. Encourage the client to hold her urine when feeling the urge to urinate. C. Restrict oral fluid intake during waking hours. D. Provide adult diapers until bladder retraining is successful.

Correct Answer is B

Explanation

A. Assisting the client to the bathroom every 2 hours may not support bladder retraining, which aims to increase the time between voids and encourage the client to recognize the need to urinate.

B. Encouraging the client to hold her urine when feeling the urge is a key component of bladder retraining, as it helps to increase bladder capacity and promotes a normal voiding pattern.

C. Restricting oral fluid intake is not recommended, as it can lead to dehydration and may not effectively aid in bladder retraining. Adequate fluid intake is essential for bladder health.

D. Providing adult diapers does not promote bladder retraining; it may enable continued incontinence rather than encouraging the client to regain control over bladder function.

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A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor for pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is B

Explanation

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