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. Requesting an indwelling urinary catheter is not appropriate for preventing skin breakdown; catheters can increase the risk of urinary tract infections and skin irritation.

B. Cleaning the skin and perineum with hot water can cause irritation and dryness. Instead, using mild soap and warm water is recommended for cleaning.

C. Checking the client's skin every 8 hours may not be frequent enough for a client with incontinence, as more frequent assessments are needed to catch signs of breakdown early.

D. Applying a moisture barrier ointment to the skin protects it from moisture and irritants, helping to prevent skin breakdown in clients with urinary incontinence. This action is proactive and aligns with best practices for skin care.

A. Kennet B. Frestat C. Dairy products D. Caffeinated beverage

Correct Answer is D

Explanation

A. "Kennet" is not a recognized food or beverage and is not known to cause bladder irritation. The question might include this as a distractor.
B. "Frestat" is also not a known food or beverage associated with bladder irritation and does not play a role in urinary incontinence management.
C. Dairy products generally do not cause bladder irritation. Although some individuals may experience sensitivity to dairy, it is not commonly associated with bladder irritation or incontinence.
D. Caffeinated beverages are known bladder irritants. Caffeine can increase urine production and stimulate bladder activity, leading to increased urgency and frequency, which can exacerbate urinary incontinence.

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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 has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Correct Answer is D

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?

Correct Answer is D

Explanation

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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.)