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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Call the health care provider, a blockage is present in the tubing: A sudden decrease in drainage can indicate a blockage in the tubing, which could lead to fluid buildup and infection. The provider should be notified so that interventions can be taken (e.g., irrigation, assessment for clot formation).
B. Remove the drain, a drain is no longer needed: The nurse should not remove the drain without a provider’s order. A decrease in drainage does not necessarily mean the wound has healed.
C. Do nothing as long as the evacuator is compressed. Even if the evacuator is compressed, a sudden decrease in drainage is abnormal and requires further investigation. Ignoring it can lead to complications like hematoma or infection.
D. Chart the results on the intake and output flow sheet. While documenting the change is important, charting alone is not an appropriate intervention. The nurse must also assess for possible causes of the decreased drainage and notify the provider.
Correct Answer is ["1170"]
Explanation
Step 1: Convert cups and ounces to mL (1 cup = 240 mL, 1 oz = 30 mL):
- Coffee: 1 cup = 240 mL
- Orange juice: 4 oz × 30 mL = 120 mL
- Water (first): 3 oz × 30 mL = 90 mL
- Flavored gelatin: 1 cup = 240 mL
- Tea: 1 cup = 240 mL
- Broth: 5 oz × 30 mL = 150 mL
- Water (second): 3 oz × 30 mL = 90 mL
Step 2: Add all the mL values together:
240 + 120 + 90 + 240 + 240 + 150 + 90 = 1,170 mL
Final Answer: 1,170 mL
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