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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 ["A","C","D"]

Explanation

Choice A rationale:

Proper nutrition with adequate protein and vitamin C is essential for wound healing as these nutrients are needed for collagen synthesis.

Choice B rationale:

Resting as much as possible and keeping the incisional area still may not necessarily aid in healing. Movement can actually promote circulation and healing.

Choice C rationale:

Increasing fluid intake to at least 4000 mL per day can help keep the body hydrated, which is beneficial for wound healing.

Choice D rationale:

Keeping skin and surrounding tissue clean and dry can help prevent infection, which can delay wound healing.

Choice E rationale:

Exercise and deep breathing can increase oxygenation, which is beneficial for wound healing.

A. Keep the wound dry. B. Help destroy microorganisms in an infected wound. C. Leave the dressing in place for 10 days. D. Occlude air and promote breakdown of necrotic tissue.

Correct Answer is D

Explanation

Choice A rationale:

Hydrocolloid dressings do not keep the wound dry; they maintain a moist environment.

Choice B rationale:

These dressings do not have antimicrobial properties.

Choice C rationale:

While these dressings can be left in place for several days, it is not their major purpose.

Choice D rationale:

Hydrocolloid dressings occlude air and promote autolytic debridement of necrotic tissue.

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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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Naxlex Comprehensive Predictor Exams

Many factors aid healing.You assist the patient to specifically improve his healing ability by encouraging (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is D

Explanation

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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?