A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

Patient ate half of his breakfast tray.

Patient has a raised erythematous rash below the knee.

Patient has a capillary refill of less than 2 seconds.

Patient is incontinent of stool.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

The choice "Patient ate half of his breakfast tray" is not the correct answer. While poor appetite or decreased intake can impact a patient's nutritional status, it is not a direct indicator of pressure ulcer risk.

Choice B rationale:

The choice "Patient has a raised erythematous rash below the knee" is not the correct answer. This might indicate a localized skin issue, such as an allergic reaction or dermatitis, but it is not a clear sign of pressure ulcer risk.

Choice C rationale:

The choice "Patient has a capillary refill of less than 2 seconds" is not the correct answer. Capillary refill time assesses peripheral circulation and is useful in evaluating perfusion, but it is not specifically indicative of pressure ulcer risk.

Choice D rationale:

The correct answer is "Patient is incontinent of stool." Choice D is the correct answer. Incontinence, especially fecal incontinence, increases the risk of pressure ulcer development. Prolonged exposure to moisture from urine or stool weakens the skin's integrity, making it more susceptible to breakdown when pressure is applied over bony prominences.

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Correct Answer is C

Explanation

Choice A rationale:

Lillian Wald is known for founding the Henry Street Settlement in New York and for her work in public health nursing and social reform, but she is not specifically associated with keeping records on sanitation techniques and their effects on health.

Choice B rationale:

Clara Barton is renowned for establishing the American Red Cross and her humanitarian efforts during the Civil War. While she contributed significantly to healthcare, her focus was not on keeping records on sanitation techniques and their effects.

Choice C rationale:

Florence Nightingale, the founder of modern nursing, is the nurse who kept records on sanitation techniques and their effects on health. She is known for her work during the Crimean War, where she improved sanitation and hygiene practices in healthcare settings, leading to significant improvements in patient outcomes.

Choice D rationale:

Mary Nutting was an influential figure in nursing education, but she is not primarily recognized for keeping records on sanitation techniques and their effects. Her contributions were more related to curriculum development and nursing education.

A. Apply petroleum jelly to the nares as needed to soothe mucous membranes. B. Remove the nasal cannula while the client eats. C. Attach a humidifier bottle to the base of the flow meter. D. Secure the oxygen tubing to the bed sheet near the client's head.

Correct Answer is D

Explanation

Choice A rationale:

Applying petroleum jelly to the nares is not necessary in this situation. Oxygen therapy through a nasal cannula aims to deliver oxygen to the client's respiratory system. Applying petroleum jelly might interfere with the oxygen delivery and is not a standard practice.

Choice B rationale:

Removing the nasal cannula while the client eats reduces the oxygen supply during a time when the body's oxygen demand might increase due to the digestive process. It's important to maintain consistent oxygen therapy, even during meals.

Choice C rationale:

Attaching a humidifier bottle to the base of the flow meter is not necessary for oxygen therapy at 5 L/min via nasal cannula. Humidification is usually needed at higher oxygen flow rates to prevent drying of the mucous membranes.

Choice D rationale:

Securing the oxygen tubing to the bed sheet near the client's head is the correct action. This ensures that the tubing is not pulled or tugged during movement, maintaining a steady flow of oxygen. Placing it near the client's head prevents kinking or tangling of the tubing and allows the client to move without disrupting the therapy.

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A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nurse kept records on sanitation techniques and the effects on health?

Correct Answer is C

Explanation

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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