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. Using an indwelling urinary catheter should be avoided unless absolutely necessary due to the associated risks of infection and other complications. It's not the first-line intervention for managing urinary incontinence.
B. Frequent toileting, also known as scheduled toileting or prompted voiding, is an effective intervention for managing urinary incontinence in older adults with dementia. It helps prevent accidents by ensuring the client has regular opportunities to use the
bathroom.
C. Reminding the client to tell the nurse when they need to urinate can be helpful, but it may not be sufficient on its own, especially for individuals with dementia who may have difficulty recognizing or communicating their needs.
D. Using adult diapers should be considered a last resort, as it does not address the underlying issue and may not promote the client's independence or dignity.
Correct Answer is C
Explanation
A. Being hard of hearing may affect the client's ability to hear and respond to questions, but it does not explain the flinching response to abdominal palpation.
B. Confusion could certainly be a factor, especially in an older adult who is found wandering. However, the specific response of flinching to abdominal palpation indicates a potential source of pain.
C. The client's flinching when the nurse palpates his abdomen is an indication of pain.
This response, along with the client's limited verbal communication (responding only by nodding and smiling), suggests that the client may be experiencing pain and is unable to express it fully.
D. While a language barrier may affect communication, it does not directly explain the client's physical response of flinching when the abdomen is palpated.
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