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
Explanation
Choice A rationale
Lying on the left side can help minimize the effects of reflux during sleep. This position helps keep the stomach contents lower than the esophagus, reducing the likelihood of acid reflux.
Choice B rationale
Lying on the right side can increase the risk of acid reflux. This position allows the stomach contents to flow more easily into the esophagus, exacerbating reflux symptoms.
Choice C rationale
Sleeping on the back with the head flat can worsen reflux symptoms. This position allows stomach acid to flow back into the esophagus more easily, increasing the risk of reflux.
Choice D rationale
Sleeping on the stomach with the head flat is not recommended for clients with GERD. This position can increase pressure on the stomach, promoting acid reflux into the esophagus.
Correct Answer is ["72"]
Explanation
Step 1 is to calculate the burned area using the Rule of Nines. The Rule of Nines assigns percentages to different body areas to estimate the total body surface area (TBSA) affected by burns. For example, each arm is 9%, each leg is 18%, the front and back of the torso are each 18%, and the head is 9%.
Step 1: Calculate the burned area. If the client has burns on the front and back of both legs, the calculation would be: (18% + 18%) + (18% + 18%) = 72%
The final calculated answer is 72%.
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