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 A

Explanation

Choice A rationale: Voiding and discarding the urine is the first step in a 24-hour urine collection to ensure that the collection starts with a fresh specimen.
Choice B rationale: Adding the first voiding to the specimen is not the correct initial step.
Choice C rationale: Keeping the urine warm during collection is important, but it is not the first step in the process.
Choice D rationale: Beginning the collection at a specific time is part of the process but not the initial step.

A. percussion. B. deep palpation. C. auscultation. D. light palpation.

Correct Answer is C

Explanation

Choice A rationale: Percussion is typically performed after auscultation in the abdominal assessment sequence.
Choice B rationale: Deep palpation is usually performed after light palpation in the abdominal assessment sequence.
Choice C rationale: Auscultation is the next step in the abdominal assessment sequence after inspection. Assessing bowel sounds is crucial before moving on to other assessment techniques.
Choice D rationale: Light palpation is often the initial step in the abdominal assessment sequence, followed by auscultation.

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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 nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?

Correct Answer is A

Explanation

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:

Correct Answer is C

Explanation

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional teaching?

The nurse is caring for a patient with a fractured left leg and is using crutches. Which statement indicates the patient has correct understanding of how to properly use her crutches?

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

When moving a client up in bed with the assistance of another caregiver, the nurse should:

0.5 mg = ______ mcg Round to the nearest whole number.

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible after a biking accident. The nurse should document this as which of the following types of wounds?

A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

Reflex incontinence is associated with neurologic dysfunction and occurs when no warning or stress precedes periodic involuntary urination.