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 C
Explanation
Choice A rationale:
Stage 3 pressure injuries involve full-thickness skin loss, but not exposure of fascia.
Choice B rationale:
Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.
Choice C rationale:
Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.
Choice D rationale:
Stage 1 pressure injuries involve non-blanchable erythema of intact skin.
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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