A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?

INR 1.1

Hyperemesis

HbA1C 5.6%

Uncontrolled pain

Answer and Explanation

The Correct Answer is B

- A: An INR of 1.1 is within the normal range, indicating normal blood clotting ability, which is essential for wound healing. A normal INR does not pose a risk for delayed wound healing.
- B: Hyperemesis can lead to dehydration and malnutrition, both of which are detrimental to wound healing. Dehydration reduces blood volume and flow, impairing the delivery of oxygen and nutrients to the wound site, while malnutrition can weaken the immune response and the formation of new tissue.
- C: An HbA1C level of 5.6% is at the high end of the normal range and does not typically indicate diabetes or impaired glucose control, which are risk factors for delayed wound healing.
- D: While uncontrolled pain can be a concern for patient comfort and may indirectly affect wound healing by reducing mobility, it is not a direct risk factor for delayed wound healing like hyperemesis is.

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

Explanation

A. The provider should renew the prescription for restraints every 24 hours, not 48 hours. This ensures regular evaluation of the need for continued restraint use.

B. Padding bony prominences helps prevent skin breakdown and injury from the restraints.

C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in case of emergency.

D. Restraints should be released every 2 hours (or as specified by the provider) to assess and provide care for the client's needs and to prevent complications such as skin breakdown or circulation impairment.

E. The provider's prescription should specify the type of restraint to be used, the reason for use, the duration, and any other relevant details to ensure appropriate and safe application.

A. Insert the catheter until a flow of urine begins. B. Attach prefilled syringe to indwelling catheter inflation hub. C. Lubricate the catheter and place fenestrated drape over perineum. D. Apply sterile gloves and place cleansing balls in antiseptic solution. E. Cleanse the meatus with the dominant hand in a downward motion.

Correct Answer is D,C,E,A,B

Explanation

D. Apply sterile gloves and place cleansing balls in antiseptic solution.

C. Lubricate the catheter and place fenestrated drape over perineum.

E. Cleanse the meatus with the dominant hand in a downward motion.

A. Insert the catheter until a flow of urine begins.

B. Attach prefilled syringe to indwelling catheter inflation hub.

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A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?

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Naxlex Comprehensive Predictor Exams

A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

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

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is D,C,E,A,B

Explanation

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