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 D
Explanation
Choice A rationale
Serosanguineous drainage is a normal finding at pin sites and does not indicate infection. It is a mixture of serum and blood and is expected during the initial healing phase.
Choice B rationale
Mild erythema around the pin sites can be a normal inflammatory response and does not necessarily indicate infection. It is important to monitor for other signs of infection.
Choice C rationale
Warmth at the pin sites can be a normal finding due to increased blood flow during the healing process. However, it should be monitored in conjunction with other signs of infection.
Choice D rationale
Fever is a systemic sign of infection and indicates that the body is responding to an infectious process. It is a critical finding that requires prompt attention and intervention.
Correct Answer is C
Explanation
Choice A rationale
Flank pain with radiation to the groin and hematuria are more indicative of kidney issues, not heart failure.
Choice B rationale
Respiratory distress, chest pain, and use of accessory muscles can indicate respiratory issues but are not specific to heart failure.
Choice C rationale
Crackles, peripheral edema, and weight gain are classic signs of heart failure. These symptoms indicate fluid overload and poor cardiac function.
Choice D rationale
Confusion, decreasing level of consciousness, and aphasia are neurological symptoms and not specific to heart failure.
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