A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.
Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?
Thick, dry, and dark area on bilateral heels.
Broken skin without evidence of undermining.
Defined area of persistent redness over bone.
Superficial sacral pressure injury with defined margins.
The Correct Answer is C
Choice A rationale
A thick, dry, and dark area on the heels could indicate a more advanced stage of a pressure injury, not the earliest indication.
Choice B rationale
Broken skin without evidence of undermining could also indicate a more advanced stage of a pressure injury.
Choice C rationale
A defined area of persistent redness over a bony prominence is often the earliest sign of a developing pressure injury. This is because these areas are more susceptible to pressure and have less padding to protect them.
Choice D rationale
A superficial sacral pressure injury with defined margins is a more advanced stage of a pressure injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Evaluating the integrity of the IV insertion site is important, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.
Choice B rationale
Encouraging the patient to take deep breaths can help with overall comfort and oxygenation, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.
Choice C rationale
Assessing distal lower extremity capillary refill can provide information about the patient’s overall circulation, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.
Choice D rationale
Inspecting the femoral site for hematoma formation is the most appropriate action in response to the patient’s complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Ulcerative colitisUlcerative colitis Explore
Correct Answer is B
Explanation
Choice A rationale
While monitoring the respiratory rate is important in a patient receiving opioids like hydromorphone, it does not directly indicate whether the patient is receiving an equianalgesic dose of the medication.
Choice B rationale
Pain scale assessment is the most direct way to evaluate if the patient is receiving an equianalgesic dose of hydromorphone. Equianalgesic refers to a dose of one opioid that would provide the same level of pain relief as a given dose of another opioid. If the patient’s pain is well-controlled, it suggests that the dose of hydromorphone is equianalgesic to the dose of the previous opioid.
Choice C rationale
Monitoring blood pressure is important in a patient receiving opioids as these medications can cause hypotension. However, blood pressure does not directly indicate whether the patient is receiving an equianalgesic dose of hydromorphone.
Choice D rationale
While it’s important to monitor the level of consciousness in a patient receiving opioids as these medications can cause sedation, it does not directly indicate whether the patient is receiving an equianalgesic dose of hydromorphone.
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