A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

A client 92 years of age who uses a walker, is incontinent, and has an extensive cardiac history

A client 45 years of age who has paraplegia

A client 68 years of age who is comatose due to a traumatic brain injury

A client 75 years of age who uses a cane and has dementia

Answer and Explanation

The Correct Answer is A

Choice A rationale: The client who is 92 years old, uses a walker, is incontinent, and has an extensive cardiac history is at higher risk for the development of pressure injuries due to age, immobility, and additional risk factors.
Choice B rationale: A client with paraplegia may be at risk for pressure injuries, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
Choice C rationale: A comatose client with a traumatic brain injury is at risk, but other factors in Choice A contribute to a higher overall risk.
Choice D rationale: A client who uses a cane and has dementia may be at risk, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.

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Correct Answer is ["148"]

Explanation

1 fluid ounce (fl oz) is approximately equal to 29.57 mL. 5 fl oz x 29.57= 147.85

=148 mL (rounded off to the nearest whole number)

A. Request a prescription for the insertion of an indwelling urinary catheter. B. Apply a moisture barrier ointment to the client's skin C. Clean the client's skin and perineum with hot water after each episode of incontinence. D. Check the client's skin every 8 hr for signs of breakdown.

Correct Answer is B

Explanation

Choice A rationale: Inserting an indwelling urinary catheter is an invasive intervention and should be reserved for specific indications. It does not prevent skin breakdown.
Choice B rationale: Applying a moisture barrier ointment to the client's skin helps protect the skin from the harmful effects of urine and prevents breakdown.
Choice C rationale: Cleaning the client's skin and perineum with hot water after each episode of incontinence can lead to skin irritation and breakdown.
Choice D rationale: Checking the client's skin every 8 hours is not sufficient to prevent skin breakdown. Continuous assessment and prompt intervention are needed.

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A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

5 fl oz = ____mL

Correct Answer is ["148"]

Explanation

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Correct Answer is B

Explanation

A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

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