How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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.
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C

Explanation

A. To confirm the placement of the NG tube:
Confirming NG tube placement is typically done using other methods, such as auscultation of air insufflation, pH testing, or X-ray. Gastric residual measurement helps assess the status of the stomach content but is not the primary method for confirming tube placement.

B. To determine the client's electrolyte balance:
While the gastric contents do contain electrolytes, the primary purpose of measuring gastric residual is to assess gastric emptying and potential feeding intolerance. It is not the most accurate method for determining overall electrolyte balance.

C. To identify delayed gastric emptying:
This is the correct and primary purpose. Measuring gastric residual helps in identifying if there's a delay in the stomach emptying the previously administered feeding, which can inform the nurse about the client's tolerance to enteral nutrition.

D. To remove gastric acid that might cause dyspepsia:
The process of measuring gastric residual doesn't involve removing gastric acid. It's more about assessing how much of the previously administered feeding remains in the stomach. If there's a high residual volume, it may suggest delayed emptying or feeding intolerance. The focus is on adjusting the feeding plan rather than removing gastric acid.

Correct Answer is C

Explanation

A. "Sweating can occur with hypoglycemia."
Explanation: This statement is correct. Sweating is one of the common symptoms of hypoglycemia. When blood glucose levels drop too low, the body releases stress hormones, including adrenaline, which can lead to sweating.

B. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: This statement is correct. Shaking or feeling shaky is a common symptom of hypoglycemia. It results from the release of stress hormones in response to low blood glucose.

C. "My son might have nausea and vomiting with hypoglycemia."Nausea and vomiting are more commonly associated with hyperglycemia, especially in diabetic ketoacidosis (DKA). They are not typical signs of hypoglycemia.

D. "The onset of low blood glucose usually occurs rapidly."Hypoglycemia often has a rapid onset, especially with missed meals or increased activity.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register