Select the 5 findings that can cause delayed wound healing.

History of diabetes mellitus.

History of hyperlipidemia.

Wound infection.

Decreased pedal perfusion.

Fasting blood glucose.

Answer and Explanation

Correct Answer : A,B,C,D,E

Choice A rationale

A history of diabetes mellitus can cause delayed wound healing due to poor blood circulation and neuropathy, which can lead to reduced sensation and increased risk of infection.

Choice B rationale

A history of hyperlipidemia can contribute to delayed wound healing by causing atherosclerosis, which reduces blood flow to the wound site and impairs healing.

Choice C rationale

Wound infection is a direct cause of delayed wound healing. Infection can lead to increased inflammation, tissue damage, and prolonged healing time.

Choice D rationale

Decreased pedal perfusion indicates poor blood flow to the lower extremities, which can significantly delay wound healing by reducing the delivery of oxygen and nutrients to the wound.

Choice E rationale

Fasting blood glucose levels are important to monitor in patients with diabetes, as high glucose levels can impair the body’s ability to heal wounds effectively.

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Correct Answer is B

Explanation

Choice A rationale

While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.

Choice B rationale

Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.

Choice C rationale

Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.

Choice D rationale

Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.

A. Remove the vest daily to inspect the client’s skin integrity. B. Check that the halo jacket is snug against the client’s skin. C. Provide range of motion to the client’s neck. D. Monitor the client for an elevated temperature.

Correct Answer is D

Explanation

Choice A rationale

Removing the vest daily is not recommended as it can disrupt the alignment and stability provided by the halo fixation device.

Choice B rationale

The halo jacket should be snug but not too tight to avoid pressure sores and discomfort.

Choice C rationale

Providing range of motion to the neck is contraindicated as the halo fixation device is meant to immobilize the cervical spine.

Choice D rationale

Monitoring for an elevated temperature is crucial as it can indicate an infection, which is a common complication with halo fixation devices.

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Select the 5 findings that can cause delayed wound healing.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?

Correct Answer is B

Explanation

A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA) to treat coronary artery disease. What information about the balloon-tipped catheter would the nurse plan to include when providing client education concerning the procedure?

A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following instructions should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine?

A nurse is providing teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?

The nurse is caring for a client prescribed digoxin to help manage heart failure. Which manifestations correlate with a digoxin level of 2.3 ng/dL? (Select all that apply.)

A nurse is admitting a client who has sustained severe burn injuries in a grease fire. Using the Rule of Nines, the nurse should estimate that the client has burned the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.

A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.

A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?

A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions?