A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

A client who has protein calorie malnutrition

A client who has type1 diabetes mellitus and is hyperglycemic

A client who has right-sided heart failure and 4+ edema to the lower extremities

A client who has postoperative delirium

A client who is ambulatory following a cardiac catheterization 4 hr ago

Answer and Explanation

Correct Answer : A

A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.

B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.

C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.

D. A client with postoperative delirium is not necessarily at risk of delirium.

E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores

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Correct Answer is C

Explanation

C. The weights in skeletal traction should not rest against the foot of the bed. Placing the weights on the floor or using a weight-bearing device such as a frame or stand is necessary to provide countertraction and maintain proper tension on the traction system.

A. In skeletal traction, the ropes or cables should be securely attached to the pins that are inserted into the bone. Proper attachment ensures that the traction force is applied effectively and safely.

B. In balanced skeletal traction, the weights on each side of the traction setup should be equal to maintain proper alignment and traction force. Balanced traction helps prevent unequal forces on the bone and surrounding tissues.

D. The ropes or cables should be properly positioned in the center of the wheel grooves to ensure smooth movement of the weights and prevent binding or friction. Proper alignment of the ropes reduces the risk of malfunction or damage to the traction equipment.

A. Impacted B. Comminuted C. Oblique D. Transverse

Correct Answer is B

Explanation

B. A comminuted fracture involves the bone being broken into multiple pieces or fragments. This description matches the scenario of the fractured tibia being splintered into several pieces.

A. An impacted fracture occurs when the bone fragments are driven into each other, causing shortening of the bone. This description does not match the scenario provided.

C. An oblique fracture occurs when the fracture line runs diagonally across the bone shaft. This description does not match the scenario provided.

D. A transverse fracture occurs when the fracture line is perpendicular to the long axis of the bone. This description does not match the scenario provided.

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A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

Correct Answer is C

Explanation

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

Correct Answer is B

Explanation

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