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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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Autonomy vs. shame and doubt focuses on developing a sense of independence and autonomy in early childhood (around 1-3 years old). It does not directly involve acceptance of death.
B. Identity vs. role diffusion pertains to adolescence (around 12-18 years old) and involves the development of a sense of self and one's role in society. It does not specifically address the acceptance of death.
C. Integrity vs. despair is the stage that occurs in late adulthood (65 years and older), where individuals reflect on their lives. Acceptance of death is a significant aspect of achieving a sense of integrity during this stage.
D. Generativity vs. stagnation occurs in adulthood (around 40-65 years old) and involves concerns about contributing to the next generation and leaving a legacy. While mortality may be a consideration, it is not the primary task of this stage.

A. Goggles B. Gown C. Mask D. Gloves

Correct Answer is C

Explanation

A. Goggles are not typically necessary for droplet precautions unless there is a risk of splashing or spraying of respiratory secretions.
B. A gown is not specifically required for droplet precautions. However, if there is a risk of contamination from respiratory secretions, a gown may be used in addition to other precautions.
C. When setting up a meal tray for a client requiring droplet precautions, the nurse should wear a mask to protect against potential exposure to respiratory droplets.
D. Gloves are not typically required for setting up a meal tray under droplet precautions, as there is no direct contact with potentially contaminated surfaces.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for several clients who are at various developmental stages. The nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development?

Correct Answer is C

Explanation

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

Correct Answer is C

Explanation

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 preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

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 assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?