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 A
Explanation
Rationale:
A. Assist the client to ambulate: Ambulation is encouraged after a laparoscopic cholecystectomy to stimulate peristalsis and help relieve abdominal distention caused by retained gas from insufflation during the procedure. It promotes bowel movement and absorption of gas, improving comfort.
B. Prepare the client for a paracentesis: Paracentesis is used to remove fluid from the peritoneal cavity, typically in clients with ascites or severe fluid retention. Abdominal distention after this procedure is usually due to gas, not fluid.
C. Insert a rectal suppository: Suppositories may stimulate bowel movements but are not the first-line intervention for post-laparoscopic gas-related distention. Encouraging natural movement through ambulation is more effective and less invasive initially.
D. Place the client in the prone position: The prone position is not typically used for relieving abdominal distention. It may cause discomfort and does not aid in gas movement through the intestines as effectively as upright or walking positions.
Correct Answer is C
Explanation
Rationale:
A. Penicillin: Saw palmetto does not interfere with antibiotic action or metabolism. No significant pharmacodynamic or pharmacokinetic interaction exists between penicillin and saw palmetto.
B. Zolpidem: While both may cause some central nervous system effects, there is no established adverse interaction between zolpidem and saw palmetto. Co-administration is generally not contraindicated.
C. Clopidogrel: Saw palmetto has antiplatelet properties and can potentiate the effects of clopidogrel, increasing the risk of bleeding. Clients taking both may face elevated risk of gastrointestinal or intracranial hemorrhage.
D. Ipratropium: Ipratropium is an anticholinergic agent used primarily for respiratory conditions. It does not have a known interaction with saw palmetto, and their pharmacologic mechanisms do not overlap.
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