A nurse is caring for a client who is scheduled for surgery.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Although important, the client's allergy to latex might have been already noted, and it may not require immediate follow-up at this moment.
B. A hematocrit of 37% is at the lower end of the normal range (37% to 47%). However, before a surgical procedure, it's crucial to ensure the client's blood volume is adequate, hence requiring immediate follow-up.
C. A prothrombin time of 21 seconds (normal range: 11 to 12.5 seconds) indicates potential issues with blood clotting and requires prompt attention before surgery.
D. A white blood cell count of 12,000/mm3 (normal range: 5,000 to 10,000/mm3) suggests an elevated count, which may indicate an infection or an inflammatory response, requiring immediate follow-up.
E. The recent intake of aspirin (80 mg) might affect the client's clotting ability. It's essential to address this before the surgical procedure.
F. While exercise history is relevant for overall health assessment, it may not require immediate action before the surgical procedure, considering other critical factors in the scenario.
Correct Answer is A
Explanation
A. Aspiration risk due to frequent coughing while eating is the priority as it can lead to aspiration pneumonia.
B. Blood pressure elevation may need attention but is secondary to the immediate risk of aspiration.
C. Nutritional intake is important, but immediate safety concerns like the risk of aspiration take precedence.
D. Leaning to the left side while sitting might indicate a motor deficit but doesn't present an immediate risk compared to aspiration.
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