A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

An adolescent who has a cervical fracture and is in a halo brace

A middle adult who has a fractured radius and an arm cast

An older adult who has a hip fracture and is in Buck's traction

A young adult who has a femur fracture and is in skeletal balanced suspension traction

Answer and Explanation

The Correct Answer is C

A. Although the adolescent in a halo brace has some immobility, the greatest risk factors for skin breakdown involve areas where prolonged pressure is applied, and older adults are more vulnerable due to age-related skin changes.

B. A fractured radius and arm cast do not pose a significant risk for skin breakdown because the client can still mobilize and reposition themselves, reducing prolonged pressure.

C. An older adult with a hip fracture in Buck's traction is at greatest risk for skin breakdown due to immobility, pressure from the traction setup, and the reduced skin elasticity and healing capacity that come with age.

D. While skeletal balanced suspension traction poses some risk, a young adult typically has better skin integrity and mobility than an older adult, reducing the risk for skin breakdown.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Cleansing the wound with 0.9% sodium chloride saline irrigation helps remove debris and bacteria from the wound surface, ensuring that the specimen collected for culture reflects the infection present in the wound rather than contaminants.

B. Including intact skin at the wound edges in the culture is not advisable, as it may introduce flora that do not represent the infection. The focus should be on obtaining a specimen from the wound itself.

C. Swabbing an area of skin away from the wound to identify normal flora is not relevant when assessing an infection. The culture should target the actual infected area to determine the causative organisms.

D. Irrigating the wound with an antiseptic prior to obtaining the specimen can alter the bacterial load present and lead to inaccurate culture results, as it may kill or wash away organisms that need to be identified.

A. Stage 1 pressure ulcer B. Stage 4 pressure ulcer C. Stage 2 pressure ulcer D. Stage 3 pressure ulcer

Correct Answer is D

Explanation

A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.

B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.

C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.

D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Correct Answer is A

Explanation

The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

Correct Answer is D

Explanation

A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

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?

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?

You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury: (Select All that Apply.)