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 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.

A. A client who has right-sided heart failure and 4+ edema to the lower extremities B. A client who is ambulatory following a cardiac catheterization 4 hr ago C. A client who has type 1 diabetes mellitus and is hyperglycemic D. A client who has protein calorie malnutrition E. A client who has postoperative delirium

Correct Answer is ["A","C","D","E"]

Explanation

A. A client with right-sided heart failure and 4+ edema is at risk for pressure ulcers due to fluid accumulation, which can impair circulation and increase the likelihood of skin breakdown.

B. A client who is ambulatory is at a low risk for pressure ulcers because frequent movement reduces the risk of prolonged pressure on any one area.

C. A client with type 1 diabetes mellitus and hyperglycemia is at risk for pressure ulcers because high blood glucose levels can impair wound healing and affect skin integrity.

D. A client with protein-calorie malnutrition is at a significant risk for pressure ulcers due to inadequate nutrition, which weakens the skin and impairs the body’s ability to repair tissue damage.

E. A client with postoperative delirium may have decreased mobility and cognitive awareness, making it harder for them to reposition themselves, thereby increasing their risk of pressure ulcers.

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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 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 providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

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?

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A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

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?

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 is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. No drainage is noted. The nurse would treat the area with which dressing to promote healing?

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.)