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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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This is the appropriate height to allow the fluid flow by gravity.
B. This is such a short distance and the fluid wouldn't flow as desired.
C. Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.
D. This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.

A. inguinal canal B. knee C. lower third of the tibia D. dorsal aspect of the foot

Correct Answer is C

Explanation

A. Inguinal canal is not the correct location for assessing the posterior tibial pulse. This area is associated with the femoral pulse.
B. The knee is not the correct location for assessing the posterior tibial pulse. This area is not directly related to the posterior tibial pulse.
C. The lower third of the tibia, anterior aspect is the correct location for palpating the posterior tibial pulse. This pulse can be found on the inside of the ankle, slightly below and behind the medial malleolus.
D. Dorsal aspect of the foot is where the dorsalis pedis pulse is located, not the posterior tibial pulse.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Correct Answer is C

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.)

A nurse is reviewing a client's prescription for 1,000 ml of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 ml of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution?

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 documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality?

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

A nurse is preparing to administer three liquid medications to a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take?

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.)

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?