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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

A. The opening of the pouch should be cut about 1/8 of an inch larger than the stoma to ensure a proper fit without restricting blood flow or irritating the stoma.

B. Placing a gauze over the stoma during a pouch change helps to absorb any discharge and keep the area clean while preparing the new appliance.

C. Povidone-iodine should not be used to clean around the stoma, as it can irritate the skin. The skin should be cleaned with mild soap and water or a recommended stoma cleanser.

D. A stoma that turns purple-blue is a sign of impaired blood flow and requires immediate medical attention. A healthy stoma should appear pink or red and moist.

E. The ostomy pouch should be emptied when it is about one-third full to prevent leakage, odor, and unnecessary pressure on the stoma.

A. Assist the client to the bathroom every 2 hr. B. Encourage the client to hold her urine when feeling the urge to urinate. C. Restrict oral fluid intake during waking hours. D. Provide adult diapers until bladder retraining is successful.

Correct Answer is B

Explanation

A. Assisting the client to the bathroom every 2 hours may not support bladder retraining, which aims to increase the time between voids and encourage the client to recognize the need to urinate.

B. Encouraging the client to hold her urine when feeling the urge is a key component of bladder retraining, as it helps to increase bladder capacity and promotes a normal voiding pattern.

C. Restricting oral fluid intake is not recommended, as it can lead to dehydration and may not effectively aid in bladder retraining. Adequate fluid intake is essential for bladder health.

D. Providing adult diapers does not promote bladder retraining; it may enable continued incontinence rather than encouraging the client to regain control over bladder function.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

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

Correct Answer is B

Explanation

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 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)?

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 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 completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply)

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

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 teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

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.)