A nurse is caring for a client.
Select the 5 findings that can cause delayed wound healing.
Potassium level.
Pre-albumin level.
History of diabetes mellitus.
History of hyperlipidemia.
Wound infection.
Decreased pedal perfusion.
Fasting blood glucose.
Correct Answer : B,C,E,F,G
Choice A rationale
Potassium level is not directly related to wound healing. While potassium is essential for overall cellular function, it does not have a direct impact on the wound healing process.
Choice B rationale
Pre-albumin level is a marker of nutritional status. Low pre-albumin levels indicate poor nutrition, which can delay wound healing. Adequate protein intake is essential for the synthesis of collagen and other proteins involved in the wound healing process.
Choice C rationale
History of diabetes mellitus can significantly delay wound healing. High blood glucose levels can impair immune function, reduce blood flow, and increase the risk of infection, all of which can delay the healing process.
Choice D rationale
History of hyperlipidemia is not directly related to wound healing. While hyperlipidemia can contribute to other health issues, it does not have a direct impact on the wound healing process.
Choice E rationale
Wound infection is a major factor that can delay wound healing. Infection can cause inflammation, tissue damage, and increased exudate, all of which can impede the healing process.
Choice F rationale
Decreased pedal perfusion indicates poor blood flow to the extremities. Adequate blood flow is essential for delivering oxygen and nutrients to the wound site, and poor perfusion can delay the healing process.
Choice G rationale
Fasting blood glucose levels are an indicator of blood sugar control. High fasting blood glucose levels can impair immune function and increase the risk of infection, both of which can delay wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["325"]
Explanation
Step 1 is to determine the total volume of fluid to be infused in the first 8 hours. According to the Parkland formula for fluid resuscitation, half of the prescribed volume is administered in the first 8 hours. Thus:
Total fluid for the first 8 hours = 5,200 mL ÷ 2 = 2,600 mL.
Step 2 is to calculate the infusion rate in mL/hr for the first 8 hours. Divide the total volume for the first 8 hours by the total time in hours:
Infusion rate = 2,600 mL ÷ 8 hr = 325 mL/hr.
Final calculated answer: 325 mL/hr.
Correct Answer is A
Explanation
Choice A rationale
Checking the circulation of the affected extremity is crucial because the greatest risk to the client is neuromuscular injury resulting from compartment syndrome. Compartment syndrome is a serious condition that occurs when there’s increased pressure within the muscles, leading to decreased blood flow, which can cause muscle and nerve damage. Early detection and intervention are essential to prevent permanent damage.
Choice B rationale
Administering additional pain medication might provide temporary relief, but it does not address the underlying issue of potential compartment syndrome. Pain unrelieved by medication is a key indicator of this condition, and addressing circulation is the priority.
Choice C rationale
Repositioning the affected extremity might help with comfort, but it does not address the potential for compartment syndrome. The primary concern is ensuring adequate blood flow to prevent tissue damage.
Choice D rationale
Documenting the findings is important for medical records, but it does not address the immediate risk of compartment syndrome. Immediate action to check circulation is necessary to prevent serious complications.
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