A nurse is caring for a client who is scheduled for surgery.

Exhibits

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

Mini Nutritional Assessment screening tool score

History of hyperlipidemia

History of malnutrition

History of diabetes mellitus

Cholesterol level

Prealbumin level

Answer and Explanation

Correct Answer : C,D,F

A.   Mini Nutritional Assessment screening tool score: While it indicates the risk of malnutrition, it's not directly linked to delayed wound healing.
B.   History of hyperlipidemia: Hyperlipidemia itself doesn't directly affect wound healing.
C.   History of malnutrition: Malnutrition significantly hampers the body's ability to heal wounds effectively.
D.   History of diabetes mellitus: Diabetes can impair wound healing due to poor blood sugar control affecting the immune system and circulation.
E.   Cholesterol level: Elevated cholesterol, while relevant to overall health, is not directly linked to delayed wound healing.
F.   Prealbumin level: Prealbumin is a marker for nutritional status; lower levels indicate inadequate protein intake and can contribute to delayed wound healing.

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Correct Answer is A

Explanation

A. Eyelashes that curl slightly outward is a normal finding.
B. Eyelids that blink involuntarily 30 to 35 times per minute may be a normal range, but it's not typically assessed during a routine eye examination.
C. Pupils of 8 to 9 mm in diameter might indicate dilation, which is not a normal finding during a regular eye assessment.
D. Corneas with an opaque appearance could indicate issues such as corneal edema or opacity, which are abnormal findings.

A. There is an area rug covering a tile floor. B. Grab bars are installed in the shower. C. Prescriptions are stored in a medication organizer. D. The hot water heater is set to 47°C (117°F).

Correct Answer is A

Explanation

Rationale for A: Area rugs pose a significant tripping hazard for older adults, especially for those with osteoporosis who are at an increased risk for fractures if they fall. The nurse should intervene by advising the client to remove the area rug to prevent falls.

Rationale for B: Grab bars installed in the shower are a safety feature that helps prevent falls, especially for clients with mobility issues. This is a positive finding and does not require intervention.

Rationale for C: Storing prescriptions in a medication organizer helps the client keep track of their medications and prevents confusion, especially in older adults. This is an effective way to manage medications and does not need intervention.

Rationale for D: The hot water heater set to 47°C (117°F) is within the safe range to prevent burns while still providing sufficient warmth for bathing. This does not pose a risk to the client, and no intervention is needed.

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A nurse is caring for a client who is scheduled for surgery. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

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A nurse is caring for a client who is scheduled for surgery.

Exhibits

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.