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.
Correct Answer : B,C,D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Alginate dressings are highly absorbent and suitable for wounds with heavy drainage. They also promote hemostasis by activating the intrinsic pathway of the clotting cascade.
Choice B rationale:
Dry gauze is not the best choice for a bleeding wound as it does not have hemostatic properties.
Choice C rationale:
Hydrogel dressings are primarily for wounds with little to no exudate and not suitable for a bleeding wound.
Choice D rationale:
Transparent dressings are thin, waterproof dressings used for superficial wounds and not suitable for a bleeding wound.
Correct Answer is A
Explanation
Choice A rationale:
Restlessness, rising pulse, and falling blood pressure are classic signs of shock, which can occur with internal hemorrhage.
Choice B rationale:
Lethargy, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.
Choice C rationale:
Headache, rising pulse, and falling blood pressure could be signs of many conditions, but they are not specific to internal hemorrhage.
Choice D rationale:
Restlessness, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.
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