A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

Patient ate half of his breakfast tray.

Patient has a raised erythematous rash below the knee.

Patient has a capillary refill of less than 2 seconds.

Patient is incontinent of stool.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

The choice "Patient ate half of his breakfast tray" is not the correct answer. While poor appetite or decreased intake can impact a patient's nutritional status, it is not a direct indicator of pressure ulcer risk.

Choice B rationale:

The choice "Patient has a raised erythematous rash below the knee" is not the correct answer. This might indicate a localized skin issue, such as an allergic reaction or dermatitis, but it is not a clear sign of pressure ulcer risk.

Choice C rationale:

The choice "Patient has a capillary refill of less than 2 seconds" is not the correct answer. Capillary refill time assesses peripheral circulation and is useful in evaluating perfusion, but it is not specifically indicative of pressure ulcer risk.

Choice D rationale:

The correct answer is "Patient is incontinent of stool." Choice D is the correct answer. Incontinence, especially fecal incontinence, increases the risk of pressure ulcer development. Prolonged exposure to moisture from urine or stool weakens the skin's integrity, making it more susceptible to breakdown when pressure is applied over bony prominences.

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Correct Answer is D

Explanation

Choice A rationale:

Hypotension is not an expected manifestation of hypoxemia during an asthma attack. Hypotension refers to abnormally low blood pressure. During an asthma attack, the body's response to hypoxemia is more likely to involve increased heart rate (tachycardia) as the heart attempts to compensate for decreased oxygen levels.

Choice B rationale:

Dysphagia is not directly related to hypoxemia during an asthma attack. Dysphagia refers to difficulty swallowing, which is not a typical respiratory manifestation. Hypoxemia in asthma is more likely to lead to symptoms such as shortness of breath, wheezing, and increased work of breathing.

Choice C rationale:

Peripheral edema is not a typical manifestation of hypoxemia during an asthma attack. Peripheral edema, or swelling in the extremities, can occur in conditions like heart failure but is not directly related to the airway constriction and reduced oxygen exchange seen in asthma attacks.

Choice D rationale:

Agitation is the correct choice. Hypoxemia, which occurs when there is a decrease in the oxygen levels in the blood, can lead to inadequate oxygen supply to the brain. This can result in neurological symptoms such as agitation, restlessness, confusion, and even loss of consciousness. Agitation is a manifestation of the body's attempt to cope with the lack of oxygen.

A. Admission assessment of a new client. B. Evaluating changes to a client's pressure ulcer. C. Performing tracheostomy care on a client. D. Administering a blood transfusion to a client.

Correct Answer is C

Explanation

Choice A rationale:

Admission assessment of a new client requires comprehensive evaluation, critical thinking, and clinical judgment. This task is within the scope of a registered nurse's responsibilities and should not be delegated to an LPN.

Choice B rationale:

Evaluating changes to a client's pressure ulcer also involves clinical judgment and assessment skills that fall within the domain of a registered nurse's role.

Choice C rationale:

This is the correct choice. Tracheostomy care involves routine and standardized procedures that an LPN can perform under the supervision of a registered nurse. LPNs are trained to provide this type of care safely and effectively.

Choice D rationale:

Administering a blood transfusion is a complex procedure that requires careful monitoring and assessment for potential adverse reactions. This task is typically within the scope of a registered nurse's practice, not an LPN's.

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A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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