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 D

Explanation

Choice A rationale: Polyuria refers to excessive production of urine, so "Inadequate elimination of urine" is not an accurate description.
Choice B rationale: Polyuria does not mean the absence of urine; rather, it implies an increased urinary volume.
Choice C rationale: Polyuria is not related to difficult or uncomfortable voiding.
Choice D rationale: Polyuria is characterized by greater than normal urinary volume, so this is the correct description.

A. Skin edges of the wound are sutured closed. B. Wound is contaminated at the time of injury. C. Granulation tissue forming at the bottom of the wound bed. D. Healing of the wound is prolonged.

Correct Answer is A

Explanation

Choice A rationale: Wound healing by first intention involves the approximation of wound edges, often closed with sutures or staples, resulting in minimal scar formation.
Choice B rationale: Contamination at the time of injury is not characteristic of wounds healing by first intention.
Choice C rationale: Granulation tissue forming at the bottom of the wound bed is characteristic of wounds healing by second intention, not first intention.
Choice D rationale: Healing of the wound is typically quicker and involves less scarring in wounds healing by first intention compared to second intention.

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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

A client at a healthcare facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record?

Correct Answer is D

Explanation

A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

The nurse is caring for a client with a wound from a biking accident. She assesses the wound and notices that the surrounding skin is very red and warm. The wound looks swollen and is draining a green like drainage. The nurse would recognize these symptoms would be a sign of what?

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select All that Apply.)

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?

Ordered: Morphine sulfate 12 mg IM Available: Morphine sulfate 15 mg/mL How many mL will you administer?

Doctor's order: 750 mL NS to infuse over 8 hours. How many mL/hr will you set the IV pump? Round to the nearest whole number.