A nurse is caring for a 68-year-old male client who was admitted to a rehabilitation unit following a repair of a right hip fracture. The client has limited mobility and requires assistance to turn and transfer out of bed. It’s Day 4, 0700hrs.
The client is at greatest risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
The client is at greatest risk for developing a Pressure ulcer due to Limited mobility.
The client’s limited mobility and the need for assistance to turn and transfer out of bed increases the risk of pressure ulcers. Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People most at risk of pressure ulcers are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","G"]
Explanation
Choice A rationale: The stoma has a bluish discoloration and is bleeding extensively. This is a significant finding that requires immediate intervention. A bluish or dusky color indicates poor blood flow to the stoma, which can lead to tissue necrosis if not addressed promptly. Extensive bleeding is also a concerning symptom that could indicate damage to the stoma or surrounding tissue. It’s important for the nurse to assess the stoma and notify the healthcare provider immediately to prevent further complications.
Choice B rationale: The skin surrounding the stoma has large open sores with oozing. This is another critical finding that needs immediate attention. Open sores and oozing can indicate a severe skin breakdown or infection, which can lead to further complications if not treated promptly. The nurse should clean the area, apply appropriate dressings, and consult with the wound care team or healthcare provider for further management.
Choice C rationale: The client is exhibiting a temperature of 37.8°C (100.0°F). While this temperature is not extremely high, it is slightly elevated and could be an early sign of infection, especially when considered in the context of the other symptoms the client is experiencing. The nurse should continue to monitor the client’s temperature and other vital signs, and report any significant changes to the healthcare provider.
Choice E rationale: The client reports increased nausea and vomiting. These symptoms can lead to dehydration and electrolyte imbalances, which can further complicate the client’s condition. The nurse should assess the client’s hydration status, provide interventions to manage nausea and vomiting, and monitor the client’s electrolyte levels.
Choice G rationale: The client refuses to participate in stoma care education. While this may not seem like an immediate medical concern, it is a significant issue that requires intervention. The client’s refusal to learn about stoma care can hinder their recovery and long-term management of the ileostomy. The nurse should explore the reasons behind the client’s refusal, provide emotional support, and use different strategies to encourage the client’s participation in stoma care education.
Correct Answer is ["31"]
Explanation
Step 1: Calculate the total volume to be infused. Total volume = 250 mL.
Step 2: Calculate the total time for the infusion in minutes. Total time = 2 hours × 60 minutes/hour = 120 minutes.
Step 3: Calculate the flow rate in mL/min. Flow rate = Total volume ÷ Total time = 250 mL ÷ 120 min = 2.08 mL/min.
Step 4: Calculate the flow rate in drops/min. Flow rate = 2.08 mL/min × 15 drops/mL = 31.25 drops/min. So, the nurse should adjust the flow rate to deliver approximately 31 drops per minute.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.