A nurse is caring for several clients who are at risk of developing a pressure injury. Which of the following clients is most at risk?

A 23-year-old client who is in skeletal traction.

A 67-year-old client who has coronary artery disease.

A 32-year-old client who has a spinal cord injury.

A 55-year-old client who has emphysema.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A 23-year-old client in skeletal traction may be at risk of pressure injuries, but being young and presumably healthier than the other options, this client may have a lower risk compared to the other choices.

Choice B rationale:

A 67-year-old client with coronary artery disease may be at risk of pressure injuries, especially if the client has limited mobility or is bedridden. However, coronary artery disease alone does not significantly increase the risk of pressure injuries.

Choice C rationale:

A 32-year-old client with a spinal cord injury is most at risk of developing a pressure injury. Spinal cord injuries often result in paralysis or limited mobility, leading to prolonged pressure on specific areas of the body, which can cause pressure ulcers.

Choice D rationale:

A 55-year-old client with emphysema may have compromised lung function, but this alone does not significantly increase the risk of pressure injuries. Pressure injuries are primarily related to immobility and pressure on specific body areas.

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Correct Answer is D

Explanation

Choice A rationale:

Administering morphine intermittent IV bolus every 2 hours is not a suitable intervention for reducing the risk of atelectasis. While pain management is important postoperatively, morphine can depress respiratory function and increase the risk of atelectasis.

Choice B rationale:

Turning the client from side to side every 4 hours is important for preventing pressure ulcers and promoting comfort, but it is not a specific intervention for reducing the risk of atelectasis.

Choice C rationale:

Providing nasotracheal suctioning for 15 to 20 seconds at a time is not a preventive measure for atelectasis. Suctioning may be necessary for airway clearance in certain situations, but it does not address the root cause of atelectasis.

Choice D rationale:

This is the correct choice. Instructing the client to hold the inhaled breath for 2 to 5 seconds with incentive spirometer use is an effective intervention to reduce the risk of atelectasis. Incentive spirometry helps to expand the lungs and improve ventilation, preventing atelectasis after surgery.

A. INR 0.8, aPTT 85 seconds. B. INR 2, aPTT 60 seconds.

Correct Answer is B

Explanation

Choice A rationale:
An INR (International Normalized Ratio) of 0.8 is within the normal range for someone not on anticoagulation therapy. The aPTT (activated partial thromboplastin time) of 85 seconds is prolonged, but it is not a reason to withhold heparin in itself. Therefore, the nurse should not withhold the medication for these values.
Choice B rationale:
An INR of 2 indicates the client's blood is taking twice as long to clot compared to the average, which can increase the risk of bleeding. The aPTT of 60 seconds is within the normal range. However, the elevated INR suggests the client might be overly anticoagulated, so the nurse should withhold the medication and notify the provider.

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A nurse is caring for several clients who are at risk of developing a pressure injury. Which of the following clients is most at risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 24 hr postoperative. Which of the following interventions should the nurse take to reduce the risk of atelectasis?

Correct Answer is D

Explanation

A nurse is caring for a client who has a deep vein thrombosis and a prescription for heparin. For which of the following findings should the nurse withhold the medication and notify the provider?

Correct Answer is B

Explanation

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