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 ["B","C","D","E"]
Explanation
E.
Choice A rationale:
Wet-to-dry dressings are not typically used for chronic wounds as they can cause tissue damage.
Choice B rationale:
Negative pressure treatment can promote healing by removing excess fluid and promoting blood flow to the wound.
Choice C rationale:
NPWT therapy, or Negative Pressure Wound Therapy, can help heal chronic wounds by removing excess fluid and promoting blood flow.
Choice D rationale:
Hydrocolloid dressings maintain a moist wound environment, which can promote healing.
Choice E rationale:
Protein is essential for wound healing as it is needed for the growth and repair of tissues.
Correct Answer is B
Explanation
Choice A rationale:
Increased pallor of the surgical site is not a typical sign of wound dehiscence. It could indicate poor blood flow to the area, but it’s not directly related to dehiscence.
Choice B rationale:
Increased serosanguineous drainage from the wound is a common sign of wound dehiscence. This type of drainage is a mixture of blood and serum, and an increase could indicate that the wound edges are separating.
Choice C rationale:
Excessive gas is not a typical sign of wound dehiscence. It could be related to other postoperative complications, such as ileus or bowel obstruction, but not specifically to dehiscence.
Choice D rationale:
Complaint of constipation is not a typical sign of wound dehiscence. It could be related to other postoperative complications, such as side effects of pain medication or decreased mobility, but not specifically to dehiscence.
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