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 B
Explanation
What is your understanding of the situation?”. This is a therapeutic response because it respects the client’s autonomy and invites them to share their concerns and feelings about the surgery.
Choice A is wrong because it is authoritarian and dismissive of the client’s feelings. It does not acknowledge the client’s right to refuse treatment.
Choice C is wrong because it is nontherapeutic and shows agreement with the client’s refusal. It also implies that the nurse and the doctor are on different sides.
Choice D is wrong because it is manipulative and guilt-tripping. It implies that the client does not care about their loved ones or their own life.
Correct Answer is C
Explanation
This is because spinach and salads contain a lot of vitamin K, which can make warfarin less effective at preventing blood clots.
Vitamin K helps the blood to clot, so eating foods high in vitamin K can counteract the effect of warfarin.
Choice A is wrong because wheat bread and butter do not contain a lot of vitamin K and do not affect warfarin.
Choice B is wrong because mangoes and tomatoes do not contain a lot of vitamin K and do not affect warfarin.
Choice D is wrong because aged cheeses and wine do not contain a lot of vitamin K and do not affect warfarin.
It is important to keep a stable diet while taking warfarin and avoid sudden changes in the amount of vitamin K intake. Foods that are high in vitamin K include green leafy vegetables, chickpeas, liver, egg yolks, avocado, and olive oil.
These foods should be limited but not eliminated from the diet. Do not drink cranberry or grapefruit juice while taking warfarin as they can increase the risk of bleeding.
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