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

Explanation

A. A significant drop in blood pressure from 138/86 mm Hg to 90/60 mm Hg indicates potential hypovolemia or hemorrhage, which requires immediate intervention to prevent shock or other complications. This is the most critical finding among the clients.

B. A client with stable blood glucose levels between 110 mg/dL and 100 mg/dL is not a priority, as these readings are within a normal range and do not indicate immediate danger.

C. The transition of wound drainage from sanguineous to serosanguineous is a normal part of the healing process and is not an urgent concern.

D. A mild increase in pain from 1 to 3 on a 1 to 10 scale is also not an immediate priority, as it remains within a low pain range and can be managed with routine pain control measures.

A. Cut the opening of the pouch one 8 of an inch larger than the stoma. B. Place a gauze over the stoma while changing the pouch. C. Use povidone-iodine to clean around the stoma. D. Expect the stoma to turn a purple-blue color as it heals. E. Empty the ostomy pouch when it becomes one-third full of contents.

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

Explanation

A. The opening of the pouch should be cut about 1/8 of an inch larger than the stoma to ensure a proper fit without restricting blood flow or irritating the stoma.

B. Placing a gauze over the stoma during a pouch change helps to absorb any discharge and keep the area clean while preparing the new appliance.

C. Povidone-iodine should not be used to clean around the stoma, as it can irritate the skin. The skin should be cleaned with mild soap and water or a recommended stoma cleanser.

D. A stoma that turns purple-blue is a sign of impaired blood flow and requires immediate medical attention. A healthy stoma should appear pink or red and moist.

E. The ostomy pouch should be emptied when it is about one-third full to prevent leakage, odor, and unnecessary pressure on the stoma.

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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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Explanation

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