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A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.

Prealbumin level.

History of diabetes mellitus.

History of hyperlipidemia.

Wound infection.

Decreased pedal perfusion.

Fasting blood glucose.

Answer and Explanation

Correct Answer : A,B,D,E,F

Choice A rationale

Prealbumin level is an important indicator of nutritional status. Low prealbumin levels can indicate poor nutrition, which can delay wound healing. Adequate protein intake is essential for tissue repair and regeneration.

Choice B rationale

History of diabetes mellitus is a significant factor that can delay wound healing. Diabetes can impair blood flow and reduce the supply of oxygen and nutrients to the wound, leading to slower healing.

Choice C rationale

History of hyperlipidemia is not directly associated with delayed wound healing. While it can contribute to other health issues, it is not a primary factor in wound healing.

Choice D rationale

Wound infection is a major factor that can delay wound healing. Infections can cause inflammation, tissue damage, and increased exudate, all of which can impede the healing process.

Choice E rationale

Decreased pedal perfusion indicates poor blood flow to the lower extremities. Adequate blood flow is crucial for delivering oxygen and nutrients to the wound site, and decreased perfusion can significantly delay healing.

Choice F rationale

Fasting blood glucose levels are important in managing diabetes. High blood glucose levels can impair the immune response and reduce the body’s ability to heal wounds effectively.

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Correct Answer is B

Explanation

Choice A rationale

A diet high in carbohydrates is not specifically recommended for diverticulitis during the asymptomatic period. While carbohydrates are an essential part of a balanced diet, they do not specifically aid in preventing diverticulitis flare-ups. Instead, a high-fiber diet is more beneficial as it helps in maintaining regular bowel movements and preventing constipation, which can reduce the risk of diverticula formation and inflammation.

Choice B rationale

A diet high in fiber is recommended during the asymptomatic period of diverticulitis. Fiber helps to soften the stool and increase its bulk, which can prevent constipation and reduce pressure on the colon. This can help prevent the formation of diverticula and reduce the risk of diverticulitis flare-ups. Foods high in fiber include fruits, vegetables, whole grains, and legumes.

Choice C rationale

A low-residue diet is typically recommended during an acute diverticulitis flare-up to reduce bowel movements and allow the colon to heal. However, during the asymptomatic period, a high-fiber diet is more beneficial in preventing future flare-ups.

Choice D rationale

A diet low in fat is not specifically recommended for diverticulitis. While reducing fat intake can be beneficial for overall health, it does not specifically address the prevention of diverticulitis flare-ups. A high-fiber diet is more effective in maintaining bowel health and preventing diverticulitis.

A. The area surrounding the insertion site feels warm to the touch. B. The infusion rate has stopped but the tubing is not kinked. C. There is fluid leaking around the insertion site. D. There is no blood return when the tubing is aspirated.

Correct Answer is A

Explanation

Choice A rationale

Warmth around the IV insertion site is a classic sign of phlebitis, which is inflammation of the vein. This can be caused by irritation from the IV catheter or the infusing solution.

Choice B rationale

A stopped infusion rate without a kinked tubing could indicate an occlusion or infiltration, but it is not a specific sign of phlebitis.

Choice C rationale

Fluid leaking around the insertion site suggests infiltration or extravasation, where the IV fluid leaks into the surrounding tissue, rather than phlebitis.

Choice D rationale

Lack of blood return when aspirating the tubing could indicate a positional issue or occlusion, but it is not specific to phlebitis.

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A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with diverticulitis has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet during the asymptomatic period?

Correct Answer is B

Explanation

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

Correct Answer is A

Explanation

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