Which of the following patients are at highest risk for developing a skin injury caused by shearing?
A patient who is lying on wrinkled sheets.
A patient who is pulled up in the bed by the nurse
A patient who is frequently incontinent.
A patient who is noted to have slough tissue
The Correct Answer is B
A. A patient who is lying on wrinkled sheets: Wrinkled sheets can cause pressure injuries, but they do not directly lead to shearing.
B. A patient who is pulled up in the bed by the nurse: Shearing occurs when the skin remains in place while underlying tissues move, often when a patient is dragged up in bed instead of lifted. This can damage skin layers and underlying tissues.
C. A patient who is frequently incontinent: Incontinence increases the risk of moisture-associated skin damage and pressure injuries but is not directly related to shearing.
D. A patient who is noted to have slough tissue: The presence of slough (dead tissue in a wound) indicates existing tissue damage but does not suggest an increased risk of shearing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "This new room has negative pressure and does six to twelve air changes an hour and disposes the air outside to reduce the infection potential in other patients. I also have to wear this surgical mask."
While this provides technical information, the surgical mask part is incorrect; the nurse should wear an N95 respirator, not a surgical mask.
B. "It sounds like you have some questions about your new diagnosis. What are you most concerned about?"
While this is a therapeutic communication technique, it does not directly answer the patient's question about airborne precautions.
C. "Tuberculosis can seriously impair the lungs and requires a long course of antibiotics to treat it."
This statement provides disease information but does not explain why airborne isolation is necessary.
D. "Tuberculosis is a small particle that can spread through the air. This new room has a special filter that reduces the spread of the bacteria through the air."
This provides a concise and accurate explanation of airborne precautions in terms the patient can understand.
Correct Answer is D
Explanation
A. Applies non-skid socks before getting the patient out of bed: Non-skid socks help prevent slipping and are an appropriate fall precaution.
B. Activates the chair alarm when the patient is sitting in the chair: Chair alarms alert staff if the patient attempts to get up unassisted, reducing fall risk.
C. Ensures that the bed is in the lowest position prior to leaving the room: Keeping the bed low reduces the severity of injury in case of a fall.
D. Places the patient on bed rest: Bed rest is not a standard fall precaution unless medically necessary. It can lead to deconditioning and further weakness, increasing fall risk.
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