The nurse understands that certain patients are more susceptible to pressure ulcer development. Which clients should the nurse identify as being at an increased risk for this health problem? Select all that apply.
Client with restricted activity
Client who can ambulate
Client with a cast
Client with good nutrition
Client with urinary and fecal incontinence
Correct Answer : A,C,E
A. Client with restricted activity - Patients with limited mobility are at a higher risk for pressure ulcers because they are unable to change positions easily, leading to prolonged pressure on certain body parts.
B. Client who can ambulate - Patients who can ambulate have the ability to shift their body weight and change positions, reducing the risk of prolonged pressure on specific areas. Ambulation can improve circulation and reduce the risk of pressure ulcers
C. Client with a cast - Clients with casts are often limited in their ability to move or change positions, making them susceptible to pressure ulcers in areas where the cast creates pressure points on the skin.
D. Client with good nutrition - Proper nutrition is essential for overall health, including skin health. Adequate nutrition promotes wound healing and tissue repair. Good nutrition is not a risk factor for pressure ulcers; in fact, it can contribute to preventing them by maintaining healthy skin.
E. Client with urinary and fecal incontinence - Incontinence can lead to moisture on the skin, making it more susceptible to breakdown. Prolonged exposure to moisture, especially in the presence of urine or feces, can increase the risk of pressure ulcer development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
To calculate the rate at which the nurse should program the pump in milliliters per hour, you can use the following formula:
Rate (mL/hour) = Volume (mL) / Time (hours)
In this case, the volume is 1,000 mL (1 liter), and the time is 5 hours. Plugging these values into the formula:
Rate (mL/hour) = 1,000 mL / 5 hours = 200 mL/hour
So, the nurse should program the pump to administer the normal saline at a rate of 200 milliliters per hour.
Correct Answer is A
Explanation
A. Urine culture and sensitivity
Explanation: A urine culture and sensitivity test involves growing bacteria from a urine sample in a laboratory setting. Once the bacteria have grown, they are exposed to different antibiotics to see which one is most effective in inhibiting their growth. This helps healthcare providers identify the specific strain of bacteria causing the infection and choose the most appropriate antibiotic treatment.
B. Serum creatinine level
Explanation: Serum creatinine level is a blood test used to measure kidney function. It evaluates how well the kidneys are filtering waste from the blood. While important for assessing kidney health, it does not determine the specific bacteria causing a urinary tract infection or the appropriate antibiotic treatment.
C. Urinalysis
Explanation: Urinalysis is a broad screening test that assesses various components in the urine, such as red and white blood cells, protein, glucose, and bacteria. While it can detect signs of a urinary tract infection (such as the presence of bacteria and white blood cells), it does not identify the specific bacterial strain causing the infection or provide information about antibiotic sensitivity.
D. Kidney scan
Explanation: A kidney scan, also known as a renal scan, is a medical imaging technique used to assess the structure and function of the kidneys. It can help diagnose conditions like kidney stones, urinary obstruction, or kidney infections. However, it does not determine the strain of bacteria causing a urinary tract infection or guide antibiotic treatment.
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