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 A
Explanation
A. Apply a moisture barrier ointment to the client's skin
Applying a moisture barrier ointment creates a protective barrier on the skin, preventing prolonged exposure to moisture, which can lead to skin breakdown in individuals with urinary incontinence. Keeping the skin dry and protected is essential in preventing skin irritation and breakdown.
B. Check the client's skin every 8 hr for signs of breakdown - Skin should be assessed more frequently, ideally every 2-4 hours, especially in clients with urinary incontinence, to detect signs of breakdown early.
C. Clean the client's skin and perineum with hot water after each episode of incontinence - Hot water can be harsh on the skin and exacerbate irritation. It's recommended to use mild, warm water and gentle cleansing techniques. Harsh cleaning methods can damage the skin.
D. Request a prescription for the insertion of an indwelling urinary catheter - Indwelling urinary catheters pose an increased risk of infection and other complications. Catheters should only be used when absolutely necessary, and preventive measures should be taken to manage incontinence without catheterization whenever possible.
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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