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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Palpate the area behind the ankle bone. This action is correct. The posterior tibial pulse is located behind the medial malleolus (ankle bone), and palpating this area is necessary to assess the pulse.
Choice B rationale
Use the pads of the fingers to feel for the pulse. This action is correct. Using the pads of the fingers provides a more sensitive and accurate assessment of the pulse compared to using the fingertips or thumb.
Choice C rationale
Compare the pulse strength with the other leg. This action is correct. Comparing the pulse strength bilaterally helps identify any discrepancies that may indicate vascular issues.
Choice D rationale
Assess for any swelling or tenderness. This action is incorrect. While assessing for swelling or tenderness is essential in a general physical examination, it is not a specific step in assessing the posterior tibial pulse.
Correct Answer is D
Explanation
Choice A rationale
The ropes being in the center of the wheel grooves is correct and ensures proper traction.
Choice B rationale
The ropes being securely attached to the pins is correct and necessary for effective traction.
Choice C rationale
The weights being equal on each side is correct and ensures balanced traction.
Choice D rationale
The weights resting against the foot of the bed is incorrect and can interfere with the effectiveness of the traction. .
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