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A nurse is caring for a client.

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

While a JP drain can help limit bleeding and clots, its primary purpose is not to control bleeding. It is more focused on preventing fluid accumulation.

Choice B rationale

A JP drain does not eliminate the need for wound irrigations. Wound irrigations may still be necessary to clean the wound and prevent infection.

Choice C rationale

The primary purpose of a Jackson-Pratt (JP) drain is to prevent drainage from accumulating in the wound. By removing excess fluid, the JP drain helps reduce the risk of infection and promotes faster healing.

Choice D rationale

A JP drain is not used for medication administration. It is specifically designed to remove fluid from the surgical site.

A. Fat neck veins. B. Hypotension. C. Poor skin turgor. D. Bradycardia. E. Pale yellow urine.

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

Explanation

Choice A rationale

Fat neck veins are not a typical finding in a client with frequent vomiting and diarrhea. Dehydration, which is common in such cases, usually leads to flat neck veins due to reduced intravascular volume.

Choice B rationale

Hypotension is a common finding in clients with frequent vomiting and diarrhea due to fluid loss and dehydration. The loss of fluids leads to a decrease in blood volume, resulting in low blood pressure.

Choice C rationale

Poor skin turgor is a classic sign of dehydration, which is expected in clients with frequent vomiting and diarrhea. Dehydration causes the skin to lose its elasticity, leading to poor skin turgor.

Choice D rationale

Bradycardia is not typically associated with dehydration. In fact, dehydration often leads to tachycardia (increased heart rate) as the body tries to compensate for the reduced blood volume.

Choice E rationale

Pale yellow urine is not a typical finding in dehydration. Dehydration usually leads to concentrated urine, which is darker in color. Pale yellow urine indicates adequate hydration.

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A nurse is caring for a client. Exhibits Select the 5 findings that can cause delayed wound healing.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?

Correct Answer is C

Explanation

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)

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

Explanation

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A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

A nurse is caring for a client.

Exhibits

Select the 5 findings that can cause delayed wound healing.