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

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"D"}

Explanation

Rationale for Correct Choices

Intravenous antibiotics: The client presents with uterine tenderness, dark foul-smelling lochia, a mildly elevated temperature, and an elevated WBC count, all of which point to endometritis, a common postpartum infection. The first-line treatment for endometritis is broad-spectrum IV antibiotics to prevent complications like sepsis.
Increase in daily fluid intake: Infection and fever can increase fluid loss through insensible means, and fluids support circulation, renal function, and antibiotic delivery. Encouraging increased fluid intake also helps address dehydration from fever and supports healing and lactation.

Rationale for Incorrect Choices

Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage and is used in trauma or suspected placental abruption in Rh-negative mothers. There is no indication of bleeding or Rh incompatibility in this case, so it is not appropriate here.
Tocolytic medication: Tocolytics are used to suppress uterine contractions in preterm labor. This client is postpartum and has no signs of preterm labor or uterine hyperstimulation, so this medication is not warranted.
Intrauterine tamponade balloon: This device is used for severe postpartum hemorrhage due to uterine atony that doesn’t respond to medical treatment. The client has moderate lochia but no signs of active hemorrhage or hemodynamic instability, so it is not indicated.

A. Platelet count B. Alanine aminotransferase (ALT) C. Blood pressure D. Hemoglobin

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

Rationale:

Platelet count: A low platelet count (<100,000/mm³) is a hallmark of HELLP syndrome but can also appear in severe preeclampsia. Therefore, thrombocytopenia supports both diagnoses.
Alanine aminotransferase (ALT): Elevated ALT indicates hepatic involvement due to hepatocellular injury, which is a defining feature of HELLP syndrome but not required for preeclampsia diagnosis.
Blood pressure: Severe hypertension (≥160/110 mm Hg), as seen in this client, is diagnostic of severe preeclampsia. It may also be present in HELLP syndrome due to overlapping pathophysiology.
Hemoglobin: Low hemoglobin can reflect hemolysis, which is part of the HELLP acronym (Hemolysis, Elevated Liver enzymes, Low Platelets). Preeclampsia does not typically present with anemia unless HELLP develops.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a postpartum unit is caring for a client. Exhibits The nurse should anticipate a provider's prescription for a(n) dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"D"}

Explanation

The nurse is continuing to care for the client. Exhibits The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

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