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. This information is important to communicate to the surgical and anesthesia team as it indicates a potential family history of adverse reactions to anesthesia. Family history of anesthesia-related complications, especially in close relatives, can influence the anesthetic plan and help mitigate potential risks during surgery.

A. Clear fluids, such as apple juice, are typically allowed up to 2 hours before surgery, but the specific fasting instructions may vary depending on the institution's protocol and the type of surgery planned.

B. This information provides insight into the patient's caffeine consumption habits but it is not typically considered a critical factor to communicate to the surgical and anesthesia team before surgery.

D. Knowing the duration of aspirin cessation allows the anesthesia team to assess the patient's coagulation status and adjust the perioperative management accordingly. However, it does not present immediate risks as significant as a family history of anesthetic complications.

A. Assess the temperature of the affected extremity. B. Adjust the prescribed weights every shift. C. Examine the skin under the traction splint. D. Monitor peripheral pulses in the affected extremity. E. Position weights against the foot of the bed.

Correct Answer is ["A","C","D"]

Explanation

A. Assessing the temperature of the affected extremity is important because changes in temperature could indicate circulation problems, which are a concern with traction. Assessing temperature helps in detecting any potential issues early on.

C. Skin integrity is crucial as traction can put pressure on the skin, potentially leading to pressure ulcers or skin breakdown. Regular examination helps in detecting any signs of skin irritation or breakdown early so that appropriate interventions can be initiated.

D. Traction can sometimes impede circulation to the affected limb, leading to complications such as compartment syndrome. Monitoring peripheral pulses helps in detecting any circulation problems promptly.

B. Adjusting the prescribed weights is not typically within the nurse's scope of practice, as the weights are determined by the physician and should not be altered without specific orders.

E. Positioning the weights against the foot of the bed is incorrect; they should hang freely to maintain effective traction.

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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.)

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