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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Mark the length to be inserted on the tube with tape: Marking the insertion length is important to ensure correct placement, but this step should occur after assessing which nare to use and preparing the client.

B. Instruct the client to hyperextend her neck: Hyperextending the neck is not recommended during NG tube insertion; instead, the client should slightly flex the neck to facilitate tube passage.

C. Place a water-based lubricant on the tip of the tube: Lubricating the tube reduces discomfort and eases insertion, but this step comes after selecting the nostril and preparing the client.

D. Compare the patency of the client’s nares: Assessing which nostril is more patent is the first priority to ensure the tube is inserted through the nare that offers the least resistance, reducing trauma and improving comfort during insertion.

A. Check the client's gastric residual. B. Verify the tube placement. C. Pour the medication into the syringe and allow it to flow by gravity. D. Clamp the NG tube for 20 to 30 min.

Correct Answer is ["B","A","C","D"]

Explanation

A. Check the client's gastric residual: After confirming tube placement, gastric residual is assessed to evaluate delayed gastric emptying, which could increase the risk of aspiration. This is done before administering medications or feedings.

B. Verify the tube placement: Tube placement is verified first to ensure the medication is delivered into the stomach and not the lungs. This prevents aspiration and other complications associated with incorrect tube placement.

C. Pour the medication into the syringe and allow it to flow by gravity: Once placement is confirmed and residual checked, the medication is administered via gravity through the syringe to minimize pressure on the NG tube and promote safe delivery.

D. Clamp the NG tube for 20 to 30 min: After administering the medication, the NG tube is clamped to allow for medication absorption before suction is resumed. Immediate suctioning would remove the medication before it can take effect.

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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 is preparing to insert a client's NG tube for enteral feedings. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

Correct Answer is ["B","A","C","D"]

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.