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 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.

A. A plaster cast requires expensive equipment for application. B. A synthetic case immobilizes bone fractures more effectively. C. A synthetic cast is weighs less. D. Drying time is prolonged with a synthetic cast.

Correct Answer is C

Explanation

C. Synthetic casts are indeed lighter in weight compared to plaster casts. This lighter weight can improve patient comfort and mobility during the healing process.

A. Plaster casts typically do not require expensive equipment for application. The materials needed for applying a plaster cast are relatively inexpensive and readily available in most healthcare settings.

B. Both the synthetic and plaster casts have relatively equal efficacy in fracture immobilization.

D. Synthetic casts typically have a shorter drying time compared to plaster casts. They may dry within 10 to 30 minutes, whereas plaster casts can take longer, often several hours, to fully dry and harden.

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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 teaching a client who has a new prescription for cyclosporine oral solution to treat rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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