You have received a report and are providing skin care for the following patients. Which patient do you want to assess first?
A 58-year-old patient with uncontrolled diabetes mellitus type two and intact skin.
A 48-year-old patient with poor nutrition, warmth and edema to the coccyx.
An 82-year-old patient with a surgical incision and approximated wound edges.
A 69 year old patient with a colostomy and blanchable erythema to the sacrum.
The Correct Answer is B
A. 58-year-old patient with uncontrolled diabetes mellitus type 2 and intact skin: While diabetes increases the risk of delayed wound healing and infection, intact skin is not an immediate concern.
B. 48-year-old patient with poor nutrition, warmth, and edema to the coccyx: Warmth and edema at a pressure site may indicate the beginning of a pressure injury or infection (e.g., cellulitis). Poor nutrition further increases the risk of skin breakdown and impaired healing, making this patient the priority for assessment.
C. 82-year-old patient with a surgical incision and approximated wound edges: A well-approximated surgical incision suggests healing is progressing normally, making this patient lower priority.
D. 69-year-old patient with a colostomy and blanchable erythema to the sacrum: Blanchable erythema is an early sign of pressure injury, but it is less concerning than warmth and edema, which suggest possible infection or worsening tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Determine the dose per administration:
- 1000 mg ÷ 250 mg/capsule = 4 capsules per dose
Calculate the total per day:
- Since the order is every 12 hours, the medication is given twice a day
- 4 capsules per dose × 2 doses per day = 8 capsules per day
Correct Answer is C
Explanation
A. Powered stand assist: Powered stand assist devices are used for clients who cannot bear weight independently, not for balance issues during ambulation.
B. Cane: A cane provides minimal support and is best for clients with mild weakness, not for those with frequent balance loss.
C. Gait belt: A gait belt provides stability and support while allowing the nurse to assist the client safely if they begin to lose balance.
D. Four-wheel walker: A four-wheel walker rolls easily, which may increase fall risk in a client with balance issues. A standard walker (without wheels) would be safer in some cases.
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