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 A

Explanation

A. The most appropriate first action would be to increase the oxygen flowrate to improve the patient's oxygen saturation levels. This intervention directly addresses the hypoxemia and can help prevent further complications related to low oxygen levels in the blood.

B. Elevating the patient's head can help improve ventilation and oxygenation. By raising the head, the patient's airway may become more patent, allowing for better airflow and oxygen exchange in the lungs. However, this should follow oxygenation.

C. Suctioning the patient's mouth aims to remove any secretions or obstructions that may be compromising the airway and contributing to the low oxygen saturation. However, this should follow oxygenation.

D. This maneuver can be helpful if the airway is obstructed by the tongue or soft tissues, potentially improving ventilation and oxygenation. However, this should follow oxygenation.

A. NSAIDS B. Anticoagulants C. Cardiac glycosides D. Thyroid hormones

Correct Answer is D

Explanation

D. Excessive thyroid hormone replacement therapy, leading to hyperthyroidism, can accelerate bone turnover and increase the risk of osteoporosis. Hyperthyroidism can disrupt normal bone remodeling processes, leading to decreased bone mineral density and increased fracture risk.

A. NSAIDs are commonly used to reduce inflammation and relieve pain. While short-term or occasional use of NSAIDs is generally safe, long-term use or high doses of NSAIDs may be associated with an increased risk of osteoporosis and bone fractures.

B. Anticoagulants, such as warfarin and heparin, are medications used to prevent blood clot formation. While anticoagulants themselves are not directly associated with osteoporosis risk, prolonged immobilization due to conditions requiring anticoagulation therapy (such as deep vein thrombosis or pulmonary embolism) can increase the risk of osteoporosis and bone loss due to decreased weight- bearing activity.

C. Cardiac glycosides, such as digoxin, are medications used to treat heart failure and certain cardiac arrhythmias. There is no direct evidence to suggest that cardiac glycosides themselves are a risk factor for osteoporosis.

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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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