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: Taking the client to the toilet when they have the urge to defecate promotes a natural bowel pattern and is an essential aspect of bowel training.
Choice B rationale: Timing toilet visits based on a regular schedule may be part of a bowel training program, but waiting for the client to have the urge is more effective.
Choice C rationale: Timing toilet visits with meals may be part of a bowel training program, but taking the client when they have the urge is more effective.
Choice D rationale: Waiting for the client to experience abdominal cramping may lead to delayed toileting and is not recommended in a bowel training program.

A. Void and discard the urine. B. Add the first voiding to the specimen. C. Keep the urine warm during collection. D. Begin the collection at a specific time.

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.

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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 implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

Correct Answer is A

Explanation

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

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?

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?

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 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?

The patient is receiving 30 mg of citalopram daily for depression. Citalopram is available in 20 mg scored tablets. How many tablets should be administered? (Round to the nearest tenth.)

5 fl oz = ____mL

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

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?