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 ["B","C","E"]

Explanation

A. At the end of the shift is incorrect. Medication verification is done before administration, not at the end of the shift.

B. When removing the medication from the medication drawer is correct. This is the first check to ensure the correct medication is selected.

C. Directly before administering the medication is correct. This is the final check to verify that the correct medication, dose, route, and time match the prescription before giving it to the client.

D. When reconciling counts of controlled substances is incorrect. While controlled substances require counting and verification, this is separate from the three medication checks performed during administration.

E. When preparing the medication dosage is correct. This is the second check, ensuring that the correct medication and dose are prepared accurately before administration.

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

A: The presence of an area rug over a tile floor poses a tripping hazard, which is particularly dangerous for individuals with osteoporosis due to the increased risk of fractures from falls. The rug can easily slip or edges can curl, leading to potential accidents. Therefore, it is crucial for the nurse to address this issue to prevent falls.

B: Grab bars in the shower are a safety feature that assists individuals in maintaining balance and preventing slips, which is beneficial for a person with osteoporosis. There is no need for intervention as this is a recommended safety measure.

C: Storing prescriptions in a medication organizer is a good practice as it helps ensure that medications are taken correctly and on time. This is especially important for older adults who may have multiple prescriptions. Thus, no intervention is needed here.

D: Setting the hot water heater to 47° C (117° F) can pose a risk of burns, especially for older adults whose skin may be more sensitive and who may have a delayed reaction to withdraw from hot surfaces. However, this is not directly related to osteoporosis, and while it is a safety concern, it is not as immediately hazardous as a tripping risk.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is A

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A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?

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.