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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
It is a legal record of accountability for the protection of the client and the nurse. This means that documentation provides evidence of the assessments and interventions that have been undertaken by the nurse and can be used to defend the nurse in case of a lawsuit or a complaint. Documentation also supports the provision of safe, high-quality patient care by facilitating continuity of care and communication among health care providers.
Choice B is wrong because it is incomplete and misleading. Documentation supports confidentiality and privacy, but it should never be shared without the client’s consent or a legal authority.
Choice C is wrong because it is too narrow. Documentation provides continuous reference for all care providers to refer to, but it also has other purposes such as quality improvement, research, education and legal protection.
Choice D is wrong because it is inaccurate. Documentation does not provide a framework for clients rights, but rather reflects how the nurse respects and upholds those rights in practice. Documentation also records if clients rights are violated, but this is not the main rationale for documentation.
Correct Answer is C
Explanation
Irrigating the tube with 30 mL of sterile saline as needed. This prescription should be questioned by the nurse because it may cause trauma to the kidney or dislodge the tube. The nurse should only irrigate the tube if ordered by the health care provider and with a smaller amount of fluid.
Choice A is wrong because monitoring the urine’s color and odor is an appropriate intervention for a client with a nephrostomy tube. The urine may be bloody or cloudy initially, but it should gradually clear.
Choice B is wrong because recording the intake and output every eight hours is also an appropriate intervention for a client with a nephrostomy tube. The nurse should measure and document the amount and characteristics of urine drainage and report any changes or abnormalities.
Choice D is wrong because measuring the vital signs every four hours during the day is a reasonable prescription for a client with a nephrostomy tube. The nurse should monitor the client for signs of infection, bleeding, or obstruction.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.