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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Correct Answer is D

Explanation

A. Cold fluids are less effective in stimulating bowel movements compared to warm fluids. Warm fluids tend to promote peristalsis and help relieve constipation, making cold fluids a less appropriate option.

B. A low-fiber diet would worsen constipation. High-fiber foods are more effective in promoting bowel regularity by adding bulk to the stool, facilitating easier passage.

C. Mineral oil is not a first-line treatment for constipation due to the risk of nutrient malabsorption and potential complications like aspiration in bedridden clients. It should be used cautiously.

D. Increasing fluid intake is an essential intervention for constipation, especially for clients on bedrest. Proper hydration softens stools and helps in promoting bowel movements, reducing the risk of constipation.

A. Apply cornstarch to keep the skin dry. B. Provide the client with a diet high in protein. C. Massage bony prominences to promote circulation. D. Reposition the client every 3 hr.

Correct Answer is B

Explanation

A. Applying cornstarch can absorb moisture; however, it may not be the most effective method to maintain skin integrity and can cause friction when applying.

B. A diet high in protein is essential for skin health and repair, as it supports tissue regeneration and helps prevent skin breakdown in vulnerable clients.

C. Massaging bony prominences is not recommended, as it may cause further tissue damage or disrupt circulation. Instead, padding and reducing pressure on these areas is more beneficial.

D. Repositioning the client every 3 hours may not be frequent enough for someone at high risk for skin breakdown; generally, repositioning should occur at least every 2 hours to alleviate pressure.

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

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

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 nurse is providing teaching to a client who has a new colostomy, and had a bowel preparation before surgery. Which of the following information should the nurse include in the teaching?

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?

A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor for pressure ulcer?

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

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

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.)