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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 C

Explanation

Choice A rationale:

Cleaning from left to right across the wound can introduce bacteria from the surrounding skin into the wound, which can lead to infection.

Choice B rationale:

Cleaning from the outer abdomen toward the wound can also introduce bacteria from the surrounding skin into the wound.

Choice C rationale:

Cleaning in a circular motion around the wound, circling to the outside, helps to move bacteria away from the wound and reduce the risk of infection.

Choice D rationale:

Cleaning directly over the wound can disrupt the healing process and potentially introduce bacteria into the wound.

A. Use small ice cubes. B. Fill the pack and refreeze it. C. Use a light cover on the pack. D. Cover the pack with plastic wrap.

Correct Answer is C

Explanation

Choice A rationale:

Using small ice cubes is not necessary when applying an ice pack. The size of the ice does not affect the therapeutic effect of the cold therapy.

Choice B rationale:

It is not necessary to fill the pack and refreeze it. The ice pack should be used as is and can be refrozen after use if needed.

Choice C rationale:

Using a light cover on the pack is necessary to prevent direct contact of the ice with the skin, which can cause cold injury or frostbite.

Choice D rationale:

Covering the pack with plastic wrap is not necessary. The ice pack usually comes in a waterproof bag that prevents water leakage.

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