Try Naxlex NCLEX-RN (Free-Trial)

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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Contacting the pharmacy might be a good step in some cases, but if the nurse has identified a dosage that is three times higher than usual, it's crucial to address this directly with the prescribing provider first.
B. Asking another nurse to verify is a reasonable step, but ultimately, it's the responsibility of the nurse who identifies the discrepancy to take action.
C. Informing the charge nurse and administering the dose without questioning the provider's order could potentially put the client at risk if the dosage is indeed too high.
D. Contacting the provider to question the dosage is the most appropriate immediate action. It's crucial to seek clarification from the provider regarding the unusually high dosage to ensure the safety and well-being of the client. This step ensures that the client receives the correct and safe medication dosage.

A. Education B. Time C. Perception D. Gender E. Feedback

Correct Answer is ["A","C","D"]

Explanation

A. Education may influence the communication process to a significant extent as an interpersonal variable.
B. Time can affect communication in terms of available time for interaction, but it is not specifically related to interpersonal variables.
C. Perception refers to how individuals interpret and make sense of information. It is a key interpersonal variable that can influence how a message is received and understood.
D. Gender can be an interpersonal variable that affects communication. Different genders may have different communication styles and preferences.
E. Feedback is not considered an interpersonl ariation that can affect communication

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.)

A nurse in a clinic is interviewing a client who will undergo diagnostic testing The nurse should ask about a client's potential allerges during which phase of the nursing process?

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?