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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?

BMI of 20.

Peripheral neuropathy.

Immobility.

Hypoperfusion.

Prealbumin level of 16 mg/dL.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of pressure injuries.

Choice B rationale:

Peripheral neuropathy can lead to decreased sensation, increasing the risk of pressure injuries as the person may not feel discomfort from prolonged pressure.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases the duration of pressure on certain areas of the body.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue damage and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is within the normal range (15-36 mg/dL), so it does not increase the risk of pressure injuries.

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Correct Answer is B

Explanation

Choice A rationale:

Strengthening the wall of the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

Choice B rationale:

Drawing the wound edges together by negative pressure is the correct answer. Vacuum-assisted closure, also known as negative pressure wound therapy, works by applying negative pressure to the wound, which helps to draw the edges of the wound together and promote healing.

Choice C rationale:

Making an air occlusive cover for the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

Choice D rationale:

Interrupting the proliferation of bacteria in the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

A. Remind him to remain very still during the procedure. B. Place a discard bag close to the wound. C. Change gloves after removing the old dressing. D. Refrain from talking while the wound is uncovered.

Correct Answer is C

Explanation

Choice A rationale:

While it’s important for the patient to remain still during the procedure, this is not the most important aspect of changing a sterile dressing.

Choice B rationale:

Placing a discard bag close to the wound can increase the risk of infection.

Choice C rationale:

Changing gloves after removing the old dressing is crucial to maintain sterility and prevent infection.

Choice D rationale:

Refraining from talking while the wound is uncovered can help prevent infection, but it’s not as important as changing gloves after removing the old dressing.

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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?

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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?