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. The client has a wound dressing saturated with sanguinous drainage after it was reinforced: Continued sanguineous drainage that saturates reinforced dressings just 2 hours post-op may indicate active bleeding or hemorrhage. This is an urgent finding that requires immediate provider notification for assessment and possible intervention.
B. The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication: A pain score of 2 reflects adequate pain control following intervention. This is an expected and desirable outcome and does not require provider notification.
C. The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter: A urine output of 50 mL/hr is within normal limits and suggests appropriate renal perfusion. No immediate action or provider notification is required based on this finding.
D. The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied: This oxygen saturation level indicates adequate oxygenation with supplemental oxygen and is within expected postoperative parameters.
Correct Answer is D
Explanation
Rationale:
A. Hypotension: Hypotension is typically associated with decreased preload and low PAWP rather than elevated values. An elevated PAWP reflects increased pressure in the left heart, which does not occur with simple hypotension alone.
B. Hypovolemia: Hypovolemia leads to decreased circulating blood volume, reducing preload and PAWP. It is typically marked by low filling pressures, not elevated wedge pressures.
C. Cardiogenic shock: Although cardiogenic shock can be associated with elevated PAWP due to poor cardiac output and fluid backup, it is not as specific a marker as left ventricular failure, which directly affects PAWP.
D. Left ventricular failure: Elevated PAWP reflects increased pressure in the left atrium and pulmonary circulation, which is a hallmark of left-sided heart failure. This elevation occurs because the failing left ventricle cannot efficiently pump blood forward.
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