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.

Answer and Explanation

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

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 D

Explanation

The correct answer is Choice D.

Choice D rationale: Keeping the nails trimmed short is crucial for a child with eczema because it minimizes the damage done when the child scratches their skin. Short nails reduce the risk of breaking the skin and causing infections or further irritation, which can exacerbate eczema symptoms. This preventive measure helps maintain the skin's integrity and reduces the risk of secondary infections.

Choice A rationale: Allowing the child to wear only 100% cotton clothing can help reduce skin irritation as cotton is a soft, breathable fabric. However, it is not as directly related to preventing the harm caused by scratching.

Choice B rationale: Applying baby lotion to the skin can help keep the skin moisturized, but it might not be sufficient for eczema management. A more intensive emollient or specific eczema treatment may be needed.

Choice C rationale: Bathing the child daily with bath oil can help moisturize the skin, but over-bathing can sometimes exacerbate eczema. It's important to use gentle, non-irritating bath products and to follow other guidelines, such as trimming nails.

A. Serum albumin. B. Hematocrit. C. Serum blood glucose (BG) level. D. Neutrophil count.

Correct Answer is D

Explanation

Choice A rationale

Serum albumin levels can be relevant in assessing nutritional status and the body’s ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage.

Choice B rationale

Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.

Choice C rationale

Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.

Choice D rationale

Neutrophil count is a key laboratory value to note when a client with a full-thickness burn has purulent drainage at the wound. An elevated neutrophil count can indicate an infection, which could be the cause of the purulent drainage.

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a 4-year-old patient with eczema. The child’s skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. What guideline is indicated for care of this child?

Correct Answer is D

Explanation

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

Correct Answer is D

Explanation

A patient admitted with an acute coronary syndrome (ACS) is receiving eptifibatide, a glycoprotein (GP) IIb IIIa inhibitor.Which assessment finding poses the greatest risk to the patient?

The patient is resting in bed and cooperative with her mother at her bedside. Which of the following assessments were made?

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea.Which source of contamination should the nurse consider when interviewing the client about exposure?

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity.Which test should the nurse schedule the client for evaluation of the symptoms?

The nurse is caring for a child with mononucleosis.Which symptoms should the nurse expect the child to exhibit?

A client newly diagnosed with type 1 diabetes mellitus (DM) asks the nurse to leave the room when the nurse tries to teach self-administration of insulin injections.What should the nurse do next?

Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

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?