The nurse understands that certain patients are more susceptible to pressure ulcer development. Which clients should the nurse identify as being at an increased risk for this health problem? Select all that apply.
Client with restricted activity
Client who can ambulate
Client with a cast
Client with good nutrition
Client with urinary and fecal incontinence
Correct Answer : A,C,E
A. Client with restricted activity - Patients with limited mobility are at a higher risk for pressure ulcers because they are unable to change positions easily, leading to prolonged pressure on certain body parts.
B. Client who can ambulate - Patients who can ambulate have the ability to shift their body weight and change positions, reducing the risk of prolonged pressure on specific areas. Ambulation can improve circulation and reduce the risk of pressure ulcers
C. Client with a cast - Clients with casts are often limited in their ability to move or change positions, making them susceptible to pressure ulcers in areas where the cast creates pressure points on the skin.
D. Client with good nutrition - Proper nutrition is essential for overall health, including skin health. Adequate nutrition promotes wound healing and tissue repair. Good nutrition is not a risk factor for pressure ulcers; in fact, it can contribute to preventing them by maintaining healthy skin.
E. Client with urinary and fecal incontinence - Incontinence can lead to moisture on the skin, making it more susceptible to breakdown. Prolonged exposure to moisture, especially in the presence of urine or feces, can increase the risk of pressure ulcer development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will reduce my intake of sodium." - This statement is correct. High sodium intake can lead to increased calcium excretion through the urine, which can weaken bones. Reducing sodium intake can help prevent osteoporosis.
B. "I will limit my intake of soft drinks." - This statement is correct. Soft drinks, especially cola beverages, contain phosphoric acid, which can leach calcium from bones, leading to decreased bone density. Limiting soft drink consumption is advisable for bone health.
C. "I will decrease my intake of caffeine." - This statement is correct. Excessive caffeine consumption can interfere with calcium absorption and increase calcium excretion. It is advisable to limit caffeine intake to prevent osteoporosis.
D. "I will reduce my intake of vitamin K-rich foods." - This statement is incorrect. Vitamin K is essential for bone health as it helps in bone mineralization and reduces the risk of fractures. Foods rich in vitamin K, such as leafy green vegetables, are beneficial for bone health and should not be reduced unless there are specific medical reasons to do so.
Correct Answer is ["500"]
Explanation
To calculate the infusion rate in ml/hr for a 500 ml bolus to be administered over 1 hour, you can simply set the pump to deliver the entire volume in the specified time:
500 ml / 1 hour = 500 ml/hr
So, the pump should be set at 500 ml/hr to administer the 500 ml bolus over 1 hour.
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