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A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?

A.

BMI of 20

B.

Peripheral neuropathy

C.

Immobility

D.

Hypoperfusion

E.

Prealbumin level of 16 mg/dL

Answer and Explanation

Correct Answer : B,C,D,E

A.    BMI of 20:
A BMI of 20 is within the normal range. While extremes of BMI, either low or high, can contribute to health issues, a BMI of 20 alone may not significantly increase the risk of pressure injuries.

B.    Peripheral neuropathy:
Peripheral neuropathy, which involves damage to the nerves in the extremities, can lead to decreased sensation and awareness. Clients with peripheral neuropathy may have difficulty sensing pressure, friction, or discomfort, making them more susceptible to pressure injuries.

C.    Immobility:
Immobility is a significant risk factor for pressure injuries. Clients who are unable to change positions frequently are more likely to develop pressure points, particularly over bony prominences. Regular repositioning is essential to prevent pressure injuries in immobile individuals.

D.    Hypoperfusion:
Hypoperfusion, or inadequate blood flow to tissues, can compromise tissue viability. Proper blood circulation is crucial for delivering oxygen and nutrients to the skin and underlying tissues. Impaired perfusion can contribute to tissue damage and increase the risk of pressure injuries.

E.    Prealbumin level of 16 mg/dL:
Prealbumin is a marker of nutritional status. A low prealbumin level (16 mg/dL) indicates malnutrition, which can impair the body's ability to repair and maintain tissues, including the skin. Malnourished individuals are at an increased risk of developing pressure injuries.
 


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Related Questions

Correct Answer is C

Explanation

A. Cimetidine:Cimetidine can indeed increase the effect of metformin due to competition for renal tubular clearance. This can lead to higher levels of metformin in the blood and potentially increase the risk of side effects. While it does not directly contraindicate metformin use, monitoring and dose adjustments might be necessary to manage this interaction.

B. Cephalexin:
Cephalexin is an antibiotic used to treat bacterial infections. It does not have a significant impact on blood glucose levels and is not contraindicated for a client taking metformin.

C. Prednisone:This is a corticosteroid that can increase blood glucose levels. Corticosteroids are known to cause hyperglycemia and may impair glucose control, which can be problematic for someone with diabetes taking metformin.

D. Levothyroxine:
Levothyroxine is a medication used to treat hypothyroidism. It does not have a direct impact on blood glucose levels and is not contraindicated for a client taking metformin.

Correct Answer is A

Explanation

A.Crackles in the lung fields indicate the presence of fluid in the lungs, which can be a sign of pulmonary edema. This is a serious adverse effect of hypertonic saline infusion (3% saline), as it can lead to fluid overload and respiratory compromise.

B.A slightly elevated heart rate (tachycardia) could occur in response to fluid shifts or the underlying condition, but it is not a specific indicator of an adverse outcome related to hypertonic saline infusion.

C.Sediment or blood in the urine is not a typical adverse outcome associated with hypertonic saline infusion. These findings may indicate a separate issue, such as a urinary tract infection or renal impairment, but they are unrelated to the administration of 3% saline for hyponatremia.

D.A rise in blood pressure may be expected as a result of volume expansion due to fluid administration, and it may even be beneficial if the patient was hypotensive.

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