A nurse is caring for a client.
Nurses' Notes
Day 1:
1300:
Client has a 2.5 cm (1 in) x 2.5 cm (1 in) stage 2 pressure injury to dorsal lateral aspect of left heal; wound bed red, moist, approximated edges; surrounding skin inflamed, red,, non-tender to palpation. Client reports pain score of 0 on 0 to 10 pain scale. Pedal pulse left foot 1+, unable to assess capillary refill due to toe fungus bilaterally, Pedal pulse right foot 2+. Wound care as prescribed; heel floated on pillow.
Medical History
Day 1:
Diabetes mellitus Hyperlipidemia
Labs
Day 1
Hct 38% (37% to 47%)
Hgb 13 (12 g/dL to 16 g/dL)
WBC 11,500/mm3 (5000 to 10,000/mm3)
Potassium 3.6 mEq/L (3.5 mEq/L to 5 mEq/L)
Pre-albumin level 10 mg/dL (15 to 36 mg/dL)
Albumin: 3.0 g/dL (3.5 to 5 g/dL)
Fingerstick blood glucose, fasting 186 mg/dL (74 to 106 mg/dL)
Select the 5 findings that can cause delayed wound healing.
Potassium level
Prealbumin level
History of diabetes mellitus
History of hyperlipidemia
Wound infection
Decreased pedal perfusion
Fasting blood glucose
Correct Answer : B,C,D,E,F
A. Potassium level is incorrect because it is within the normal range and does not affect wound healing directly.
B. Prealbumin level is correct because it is low, indicating malnutrition and poor protein intake, which are essential for tissue repair and immune function.
C. History of diabetes mellitus is correct because it causes impaired blood flow, increased risk of infection, and delayed inflammatory response, which all hinder wound healing.
D. History of hyperlipidemia is correct because it causes atherosclerosis and reduced blood supply to the affected area, which limits oxygen and nutrient delivery to the wound.
E. Wound infection is correct because it increases inflammation, tissue damage, and metabolic demands, which prolong the healing process and may lead to complications.
F. Decreased pedal perfusion is correct because it indicates poor circulation to the lower extremities, which impairs wound healing by reducing oxygen and nutrient delivery to
the wound.
G. Fasting blood glucose is incorrect because it is not a direct cause of delayed wound healing, but rather a reflection of the client's diabetes management. However, high blood glucose levels can impair wound healing by affecting blood flow, immune function, and collagen synthesis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. He is hard of hearing:
This is unlikely. While hearing impairment could explain some difficulty in communication, it would not explain the flinching upon abdominal palpation or the wandering behavior. Hearing-impaired clients typically respond to nonverbal cues or attempt to communicate their understanding in other ways.
B. Confusion:
This is correct. The client's wandering behavior, lack of verbal response, and smiling/nodding without clear understanding are indicative of confusion, which is common in older adults experiencing delirium, dementia, or other cognitive impairments. The flinching during abdominal palpation suggests a physical issue, but the client's inability to articulate his discomfort further supports confusion as a contributing factor.
C. Pain:
While pain could explain the flinching during palpation, it does not account for the wandering behavior or the lack of meaningful verbal communication. Pain may coexist with confusion but is not the primary explanation for his overall behavior.
D. Language barrier:
A language barrier could explain difficulty in verbal communication, but it does not account for the wandering behavior or the flinching upon palpation. Additionally, the family’s ability to communicate with the healthcare team suggests this is not the most likely factor
Correct Answer is B
Explanation
A. The head of the bed should generally be elevated no more than 30° to reduce shear and friction, not 45°.
B. Using a transfer device to lift the client prevents shearing and friction, which helps maintain skin integrity and reduces the risk of pressure ulcers.
C. Massaging bony prominences is not recommended, as it can damage underlying tissue and increase risk of ulcer formation.
D. Cornstarch is not advised because it can create a moist environment that promotes skin breakdown and infection.
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