A nurse is assisting in the care of a client who is scheduled for surgery.

Exhibits
The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing. Select all that apply.

History of diabetes mellitus

Prealbumin level

Cholesterol level

Mini Nutritional Assessment screening tool score

History of malnutrition

History of hyperlipidemia

Answer and Explanation

Correct Answer : A,B,D,E

A. History of diabetes mellitus: Diabetes causes impaired blood flow and neuropathy, which delay wound healing by reducing oxygen and nutrient delivery to tissues and increasing infection risk.

B. Prealbumin level: A low prealbumin level reflects inadequate protein stores, which are critical for cellular repair, immune function, and the synthesis of collagen during wound healing.

C. Cholesterol level: While elevated cholesterol increases cardiovascular risk, it does not directly affect the biochemical processes involved in wound healing or tissue repair.

D. Mini Nutritional Assessment screening tool score: A low score indicates poor nutritional status, often linked with deficiencies in vitamins, minerals, and protein that are necessary for effective tissue repair and immune response.

E. History of malnutrition: Malnutrition results in diminished energy reserves and nutrient deficiencies, both of which weaken the body's capacity to regenerate tissue and fight infections, prolonging wound healing time.

F. History of hyperlipidemia: Hyperlipidemia contributes to atherosclerosis but is not directly associated with impaired wound healing or immune function necessary for tissue recovery.

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Correct Answer is ["B","D","E"]

Explanation

A. Room number: Room number is not a reliable client identifier because clients can be moved or rooms reassigned, which increases the risk of medication errors or misidentification.

B. Photo identification: Using photo identification is a reliable way to confirm the client’s identity, ensuring that medications are given to the correct person by visually matching the client’s face.

C. Diagnosis: Diagnosis alone is not a unique identifier since multiple clients can share the same diagnosis, and it does not confirm identity for medication administration purposes.

D. Facility-assigned identification number: This number is a unique identifier assigned to each client and is commonly used in healthcare settings to verify identity accurately before medication administration.

E. Date of birth: Date of birth is a reliable identifier to cross-check client identity, especially when used with other identifiers, reducing the risk of errors during medication administration.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for Correct Answers:

Turn the client to their side: This is a crucial first action. During a seizure, turning the client to their side (recovery position) helps to maintain an open airway, prevent aspiration of saliva or vomitus, and allow secretions to drain from the mouth.
Call for assistance: After ensuring the client's safety and positioning, the nurse should call for help to ensure appropriate and prompt support from the healthcare team.

Rationale for Incorrect Answers:

Restrain the client: Restraining a client during a seizure can cause injury. Instead, ensure the area is safe and the client is protected from harm without restricting movement.
Place a tongue blade in the client’s mouth: This is unsafe and outdated. Inserting anything in the mouth during a seizure can break teeth or obstruct the airway.
Administer lorazepam: Although lorazepam is used to treat ongoing prolonged seizures, it is not the first action in this scenario. Medication administration follows basic safety measures and calling for support.

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A nurse is assisting in the care of a client who is scheduled for surgery. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing. Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is preparing to administer medications to a group of clients. Which of the following are acceptable client identifiers for the nurse to use? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is assisting in the care of a client. Exhibits Complete the following sentence by using the lists of options. At 1000 the nurse enters the client's room. The first action the nurse should take is dropdown followed by dropdown .

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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A nurse is assisting in the care of a client who is scheduled for surgery.

Exhibits
The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing. Select all that apply.