Which older adult on bed rest is most at risk to develop skin breakdown? A client who:.

Applies powder after drying the skin.

Has been NPO for four days.

Bathes twice a week.

Has hypertension.

Answer and Explanation

The Correct Answer is B

A client who has been NPO for four days is most at risk to develop skin breakdown. This is because being NPO (nothing by mouth) can lead

to malnutrition and dehydration, which are both risk factors for bedsores. Malnutrition can impair the skin’s ability to heal and resist infection, while dehydration can make the skin dry and fragile.

Choice A is wrong because applying powder after drying the skin can help prevent moisture and friction, which are also risk factors for bedsores.

Choice C is wrong because bathing twice a week may not be frequent enough to keep the skin clean and free of irritants, which can also contribute to bedsores.

Choice D is wrong because hypertension (high blood pressure) does not directly cause bedsores, although it may be associated with other conditions that affect blood circulation and tissue oxygenation.

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Correct Answer is C

Explanation

Orthostatic hypotension noted with dangling.

This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.

The nurse should document this finding and report it to the physician.

Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.

Choice B is wrong because the gait belt applied is not a finding but an intervention.

Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.

Choice E is wrong because spot accucheck obtained is not a finding but an action.

Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.

Choice G is wrong because provided reassurance is not a finding but a nursing measure.

A. Select an insulin syringe, 31 gauge 6 mm needle and inject insulin at a 45-degree angle. B. Select a 0.5 mL syringe, 30 gauge, 8 mm needle and inject at a 90-degree angle. C. Select a 0.5 mL syringe, 29 gauge 8 mm needle, pinch the skin, and inject at 45 degrees. D. Select a 1.0 mL syringe, 28 gauge 12.7 mm needle, and inject at 90 degrees.

Correct Answer is B

Explanation

Select a 0.5 mL syringe, 30 gauge, 8 mm needle and inject at a 90-degree angle. This is because Humulin R is a clear and colorless solution that can be given by subcutaneous injection.

A 0.5 mL syringe can hold up to 50 units of insulin, which is enough for the prescribed dose of 7 units. A 30 gauge, 8 mm needle is suitable for thin patients with poor skin turgor. Injecting at a 90-degree angle ensures that the insulin reaches the subcutaneous tissue and not the muscle.

Choice A is wrong because a 31 gauge, 6 mm needle is too short and may not deliver the insulin into the subcutaneous tissue.

Choice C is wrong because pinching the skin is not necessary for thin patients with poor skin turgor.

Choice D is wrong because a 1.0 mL syringe is too large for the prescribed dose of 7 units and may cause dosing errors. A 28 gauge, 12.7 mm needle is too long and may inject the insulin into the muscle, which can affect its absorption and action.

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Which older adult on bed rest is most at risk to develop skin breakdown? A client who:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?

Correct Answer is C

Explanation

The client has diabetes Type I, a body mass index (BMI) of 17 and poor skin turgor. How should the nurse plan to administer the prescribed. Humulin R 7 units subcutaneously?

Correct Answer is B

Explanation

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