Which patient is most at risk for pressure ulcer formation?

The patient with a poor appetite for 3 days

The patient with a raised red rash on the right shin

The patient with a capillary refill less than 2 seconds

The patient with fecal incontinence

Answer and Explanation

The Correct Answer is D

Choice A reason: Poor appetite for 3 days may lead to nutritional deficits, increasing ulcer risk long-term, but immediate risk is lower. Fecal incontinence causes ongoing moisture, making it a higher priority risk factor.

Choice B reason: A raised red rash on the shin may indicate irritation or infection but does not directly contribute to pressure ulcer formation. Incontinence-related moisture is a greater risk, making this incorrect.

Choice C reason: Capillary refill less than 2 seconds indicates normal perfusion, not a risk for pressure ulcers. Poor perfusion increases risk, but incontinence’s moisture directly threatens skin integrity, making this incorrect.

Choice D reason: Fecal incontinence increases pressure ulcer risk by exposing skin to moisture and irritants, causing maceration and breakdown. This is a primary risk factor, making it the patient most at risk.

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Correct Answer is A

Explanation

Choice A reason: A Kayexalate enema for severe hypokalemia should be questioned, as Kayexalate removes potassium to treat hyperkalemia, not hypokalemia. Administering it for low potassium would worsen the condition, risking arrhythmias, making this an incorrect and dangerous order.

Choice B reason: A hypertonic solution enema for fluid volume excess is appropriate, as it draws fluid into the bowel, aiding evacuation and reducing systemic fluid overload. This aligns with the patient’s condition, making it a correct order that does not require questioning.

Choice C reason: A normal saline enema repeated until stool is produced is safe, as saline is isotonic and effective for constipation relief without causing fluid or electrolyte imbalances. This is a standard order, making it appropriate and not requiring no questioning.

Choice D reason: An oil retention enema for constipation is appropriate, as it lubricates stool, facilitating evacuation. This is a standard treatment for relieving constipation, aligning with the patient’s needs, making it a correct order that does not require questioning.

A. Encourage the client to ambulate every 4 hours B. Administer a prescribed analgesic C. Apply a warm compress to the incision D. Instruct the client to avoid deep breathing

Correct Answer is B

Explanation

Choice A reason: Ambulation every 4 hours prevents complications like thrombosis but does not directly relieve incisional pain. Analgesics address pain immediately, making ambulation a secondary intervention.

Choice B reason: Administering a prescribed analgesic directly relieves incisional pain, improving comfort and recovery. Pain management is a priority post-cholecystectomy, making this the correct action for the nurse to take.

Choice C reason: A warm compress may increase bleeding or swelling at the incision site. Analgesics are safer and more effective for pain relief, making this an incorrect for postoperative care.

Choice D reason: Avoiding deep breathing risks infection, a postoperative complication. Analgesics relieve pain, enabling deep breathing to promote lung expansion, making this incorrect and counterproductive.

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Which patient is most at risk for pressure ulcer formation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of these enema orders would should the nurse question?

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative following a cholecystectomy and reports incisional pain. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?

Which patient using an inhaler would benefit most from using a spacer?

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A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse take?

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A nurse is caring for a client who has a prescription for NPH insulin 20 units subcutaneous daily. The nurse should plan to administer this medication at which of the following times?