A patient is incontinent the first day after his surgery.
This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:
The patient has to be repositioned for the bed to be changed.
Shearing is more likely from wet sheets.
The moisture creates an environment suitable for the growth of microorganisms in a wound.
Greater pressure is exerted by a wet bed.
The Correct Answer is C
Choice A rationale:
Repositioning the patient for bed changing does not directly contribute to skin breakdown or infection.
Choice B rationale:
While shearing can cause skin breakdown, it is not directly related to incontinence or wet sheets.
Choice C rationale:
Moisture from incontinence can create an environment suitable for the growth of microorganisms in a wound, leading to infection and skin breakdown.
Choice D rationale:
A wet bed does not exert greater pressure on the patient’s skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
E.
Choice A rationale:
A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of a pressure injury.
Choice B rationale:
Peripheral neuropathy can lead to a loss of sensation, which increases the risk of a pressure injury as the individual may not feel discomfort or recognize the need to reposition.
Choice C rationale:
Immobility is a major risk factor for pressure injuries as it increases pressure on certain areas of the body, reducing blood flow and leading to tissue damage.
Choice D rationale:
Hypoperfusion, or reduced blood flow, can lead to tissue hypoxia and increase the risk of pressure injuries.
Choice E rationale:
A prealbumin level of 16 mg/dL is at the lower end of the normal range (15-36 mg/dL)2. Low prealbumin levels can indicate poor nutritional status, which is a risk factor for pressure injuries.
Correct Answer is A
Explanation
Choice A rationale:
Dakin solution is used for chemical debridement of a wound.
Choice B rationale:
Primary intention is a method of wound healing, not a result of Dakin solution.
Choice C rationale:
While Dakin solution can aid in wound healing, it does not directly cause healing.
Choice D rationale:
Phagocytosis is a process carried out by certain cells in the body, not a result of Dakin solution.
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