A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?

Shortness of breath

Adequate dietary intake

Decrease level of consciousness

Muscular Pain

Answer and Explanation

The Correct Answer is C

A. Shortness of breath: While respiratory issues can reduce oxygenation and indirectly affect healing, shortness of breath is not a direct risk factor for pressure ulcer development.

B. Adequate dietary intake: Adequate nutrition prevents pressure ulcers rather than increasing the risk. Poor dietary intake, particularly protein and vitamin deficiencies, is a risk factor.

C. Decreased level of consciousness: Patients with a decreased level of consciousness (e.g., sedated, comatose, or confused patients) are at higher risk for pressure ulcers due to immobility, lack of repositioning, and unawareness of discomfort.

D. Muscular pain: While pain can limit movement, it is not a primary risk factor for pressure ulcer development. Immobility and prolonged pressure are the key contributors.

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Correct Answer is A

Explanation

A. Tell the client to blow his/her nose gently before the instillation of the drops. Blowing the nose clears the nasal passages, allowing the medication to reach the mucosa effectively.

B. Assist the client to a side-lying position. The correct position is head tilted backward (supine with neck hyperextended) or head tilted slightly to the side to ensure proper absorption. A side-lying position is not appropriate for nasal drops.

C. Hold the dropper 2 cm (1 inch) above the nares. The dropper should be placed just inside the nostril without touching it to prevent contamination. Holding it too high may cause the drops to miss the nasal mucosa.

D. Instruct the client to stay in the same position for 2 minutes. Remaining in position for at least 5 minutes allows the medication to be absorbed without draining out of the nasal cavity.

A. Disposable measuring tape B. Cotton-tipped applicator C. Natural light D. Sterile gloves

Correct Answer is C

Explanation

A. Disposable measuring tape: While measuring the wound is important, assessing the wound’s color and depth should be the first step to determine staging.

B. Cotton-tipped applicator: A cotton-tipped applicator is useful for assessing undermining or tunneling, but it is not the first step in staging a pressure ulcer.

C. Natural light: In darkly pigmented skin, color changes may not be obvious under artificial lighting. Using natural light helps the nurse detect early signs of skin breakdown.

D. Sterile gloves: Gloves are necessary for infection control, but they do not assist in staging the ulcer. First, assess the wound using natural light.

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A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?

Correct Answer is C

Explanation

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