A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?
A client 92 years of age who uses a walker, is incontinent, and has an extensive cardiac history
A client 45 years of age who has paraplegia
A client 68 years of age who is comatose due to a traumatic brain injury
A client 75 years of age who uses a cane and has dementia
The Correct Answer is A
Choice A rationale: The client who is 92 years old, uses a walker, is incontinent, and has an extensive cardiac history is at higher risk for the development of pressure injuries due to age, immobility, and additional risk factors.
Choice B rationale: A client with paraplegia may be at risk for pressure injuries, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
Choice C rationale: A comatose client with a traumatic brain injury is at risk, but other factors in Choice A contribute to a higher overall risk.
Choice D rationale: A client who uses a cane and has dementia may be at risk, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Protective supine positioning is not ideal for managing dysphagia or facilitating swallowing.
Choice B rationale: Semi-Fowlers positioning, with the head of the bed elevated at a 30 to 45-degree angle, is often recommended for clients with dysphagia. This position helps prevent aspiration during eating and promotes effective swallowing.
Choice C rationale: Low-Fowlers and Fowlers positions may not be as effective in preventing aspiration during eating as the Semi-Fowlers position.
Choice D rationale: Fowlers positioning alone may not be sufficient for managing dysphagia; Semi-Fowlers is a more specific recommendation.
Correct Answer is ["148"]
Explanation
1 fluid ounce (fl oz) is approximately equal to 29.57 mL. 5 fl oz x 29.57= 147.85
=148 mL (rounded off to the nearest whole number)
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