A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?
A client who has dementia and is incontinent of urine
A client who is 2 days postoperative following orthopedic surgery
A client who has a T-tube following an open cholecystectomy
A client who has had a recent myocardial infarction
The Correct Answer is A
Rationale:
A. A client who has dementia and is incontinent of urine: This client has multiple contributing factors, cognitive impairment limits repositioning and self-care, while urinary incontinence increases skin moisture and maceration, promoting skin breakdown and pressure injury formation.
B. A client who is 2 days postoperative following orthopedic surgery: Although this client may have limited mobility, they are typically on a monitored recovery path with interventions like repositioning, early ambulation, and pain management, reducing their overall risk.
C. A client who has a T-tube following an open cholecystectomy: This client is generally alert, mobile with assistance, and able to communicate needs, which lowers their risk of pressure injury compared to more dependent individuals.
D. A client who has had a recent myocardial infarction: This client may be monitored in bed rest initially, but cardiovascular stability and mobility often improve quickly with treatment, making their pressure injury risk moderate rather than the highest among the group.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Rationale for correct choices:
- Macrosomia: Post-term infants (≥42 weeks gestation) have prolonged exposure to intrauterine nutrients, increasing the risk of excessive fetal growth. Macrosomia is common and can lead to complications such as shoulder dystocia or birth trauma.
- Meconium aspiration syndrome: As gestation progresses beyond term, placental function may decline, increasing fetal stress. This can trigger passage of meconium in utero and aspiration during delivery, especially with late decelerations suggesting uteroplacental insufficiency.
Rationale for incorrect choices:
- Intraventricular hemorrhage: This condition is typically associated with preterm infants due to fragile cerebral vasculature. A post-term newborn is not at increased risk for IVH.
- Bronchopulmonary dysplasia: BPD is a chronic lung disease most often seen in premature infants requiring prolonged mechanical ventilation and oxygen therapy. It is not a common concern for post-term infants.
Correct Answer is C
Explanation
Rationale:
A. Pain level of 1 on a scale of 0 to 10: A low pain score suggests effective pain management and is not associated with poor wound healing. In fact, well-controlled pain can facilitate mobility and participation in recovery activities, both of which support healing.
B. Capillary refill time 1 second: This finding reflects good peripheral perfusion, indicating adequate circulation and oxygen delivery to tissues, which are essential for optimal wound healing.
C. BMI 35: A BMI of 35 indicates obesity, which is a known risk factor for delayed wound healing. Excess adipose tissue reduces vascularity, increases tension on wound edges, and raises the risk of infection and dehiscence.
D. Oxygen saturation 97% on room air: Normal oxygen saturation ensures tissues are receiving sufficient oxygen to support cellular repair and regeneration. This value supports wound healing rather than delaying it.
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