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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Cyclosporine is typically taken on an empty stomach, either 1 hour before or 2 hours after a meal, to improve absorption. Taking it with food, especially high-fat meals, can decrease absorption and effectiveness.
A. Grapefruit juice can interact with cyclosporine, leading to increased blood levels of the medication and potentially causing toxicity. Therefore, clients should be advised to avoid grapefruit juice when taking cyclosporine.
B. Mixing cyclosporine oral solution with chocolate milk or any other liquid should be done only if directed by the healthcare provider or as specified in the medication instructions.
C. Using a plastic container to mix the oral solution may reduce the risk of interaction compared to using metal or glass containers. However, it's important to follow the specific instructions provided with the medication.
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.
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