Which of the following patients are at highest risk for developing a skin injury caused by shearing?
A patient who is lying on wrinkled sheets.
A patient who is pulled up in the bed by the nurse
A patient who is frequently incontinent.
A patient who is noted to have slough tissue
The Correct Answer is B
A. A patient who is lying on wrinkled sheets: Wrinkled sheets can cause pressure injuries, but they do not directly lead to shearing.
B. A patient who is pulled up in the bed by the nurse: Shearing occurs when the skin remains in place while underlying tissues move, often when a patient is dragged up in bed instead of lifted. This can damage skin layers and underlying tissues.
C. A patient who is frequently incontinent: Incontinence increases the risk of moisture-associated skin damage and pressure injuries but is not directly related to shearing.
D. A patient who is noted to have slough tissue: The presence of slough (dead tissue in a wound) indicates existing tissue damage but does not suggest an increased risk of shearing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Determine the dose per administration:
- 1000 mg ÷ 250 mg/capsule = 4 capsules per dose
Calculate the total per day:
- Since the order is every 12 hours, the medication is given twice a day
- 4 capsules per dose × 2 doses per day = 8 capsules per day
Correct Answer is C
Explanation
A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.
B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.
C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.
D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.
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