You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury:
(Select All that Apply.)

A 5-year-old female who is a quadriplegic.

A 5-year-old with a Braden Scale score of 7.

A 5-year-old female who has controlled diabetes and is ambulating three times a day.

A 35-year-old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint.

Answer and Explanation

Correct Answer : A,B,D

A. A quadriplegic client is at high risk for pressure injuries due to immobility and lack of sensation, which can lead to prolonged pressure on skin and tissues.

B. A Braden Scale score of 7 indicates severe risk for pressure injuries. The lower the Braden score, the higher the risk, with scores less than 9 signifying very high risk.

C. A client with controlled diabetes who is ambulating frequently is not at high risk for pressure injuries because mobility reduces the risk of sustained pressure.

D. A BMI of 13.6 indicates severe underweight status, and incontinence of stool increases moisture, both of which elevate the risk of pressure injuries. Additionally, the splint on the leg may create pressure points.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Clients receiving continuous bladder irrigation after a transurethral resection of the prostate (TURP) often feel a constant urge to void due to the presence of the catheter and the irrigation fluid in the bladder. The nurse should reassure the client that this sensation is expected.

B. Weighing the client is not necessary for immediate postoperative care following TURP. Fluid balance is managed by monitoring urine output rather than daily weight.

C. Urine output should be monitored more frequently than every 6 hours in the immediate postoperative period, especially with continuous bladder irrigation, to ensure there are no blockages or complications.

D. Fluid restriction is not recommended after TURP. In fact, encouraging oral fluid intake helps maintain hydration and prevents blood clots in the bladder irrigation system.

A. Application of antibiotic ointment to the arm of a client who has dermatitis B. Removal of the nasogastric tube of a client who has been receiving enteral feedings C. Monitoring vital signs of a client who had an appendectomy 12 hr ago D. Obtaining medical history information from a stable client who is being admitted

Correct Answer is C

Explanation

A. Application of antibiotic ointment involves assessment and clinical judgment, which should be performed by a licensed nurse rather than an AP.

B. The removal of a nasogastric tube is a nursing task that requires training and knowledge of potential complications, and it should not be assigned to an AP.

C. Monitoring vital signs of a client who had an appendectomy 12 hours ago can be safely delegated to an AP, as it is a basic task that does not require clinical judgment beyond standard procedures.

D. Obtaining medical history information from a stable client is a task that requires assessment skills and critical thinking, making it inappropriate to assign to an AP.

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You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury: (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?

Correct Answer is C

Explanation

A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

Mr. Jones injured his left shin 4 days ago. Upon removal of the dressing, the wound is noted to be red, no slough or drainage. Surrounding tissue is swollen and is painful to the touch. The wound measures 3cm by 5 cm. What phase of healing is the wound in?

A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?

A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury:
(Select All that Apply.)