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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

Explanation

Choice A rationale:

The supine position with the head tilted toward the right eye allows the solution to flow away from the nose and mouth, preventing aspiration or discomfort.

Choice B rationale:

An upright position with the head tilted toward the left eye would cause the solution to flow into the nose and mouth, which could lead to aspiration or discomfort.

Choice C rationale:

An upright position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

Choice D rationale:

A supine position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

A. Irrigate the wound until the solution that is draining is clear. B. Chill the irrigant prior to the procedure. C. Hold the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating. D. Flush the wound from the most contaminated area to the cleanest area.

Correct Answer is A

Explanation

Choice A rationale:

The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.

Choice B rationale:

The irrigant should be at room temperature, not chilled.

Choice C rationale:

The syringe should be held 1 inch (not 0.5 inch) from the wound.

Choice D rationale:

The wound should be flushed from the cleanest area to the most contaminated, not the other way around.

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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

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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?