You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury:
(Select All that Apply.)
A 5-year-old female who is a quadriplegic.
A 5-year-old with a Braden Scale score of 7.
A 5-year-old female who has controlled diabetes and is ambulating three times a day.
A 35-year-old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint.
Correct Answer : A,B,D
A. A quadriplegic client is at high risk for pressure injuries due to immobility and lack of sensation, which can lead to prolonged pressure on skin and tissues.
B. A Braden Scale score of 7 indicates severe risk for pressure injuries. The lower the Braden score, the higher the risk, with scores less than 9 signifying very high risk.
C. A client with controlled diabetes who is ambulating frequently is not at high risk for pressure injuries because mobility reduces the risk of sustained pressure.
D. A BMI of 13.6 indicates severe underweight status, and incontinence of stool increases moisture, both of which elevate the risk of pressure injuries. Additionally, the splint on the leg may create pressure points.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["890"]
Explanation
Answer= 890 ml
To calculate the total intake, we need to convert all the volumes to a common unit, such as milliliters (mL).
- Clear soda: 4 oz = 120 mL (1 oz = 30 mL)
- Toast: Assuming 1 slice of toast is approximately 50 mL.
- Water: 12 oz = 360 mL (1 oz = 30 mL)
- Fruit-flavored gelatin: 1 cup = 240 mL
- Chicken broth: 1/2 cup = 120 mL
Now, add up all the intakes:
- 120 mL + 50 mL + 360 mL + 240 mL + 120 mL = 890 mL
Correct Answer is B
Explanation
A. Sanguineous drainage is characterized by bright red blood; it indicates fresh bleeding and does not include watery components.
B. Serosanguineous drainage is a combination of clear, watery fluid and blood, often appearing light pink to red. The description of watery red drainage fits this category, making it the correct choice.
C. Serous drainage is clear, pale yellow fluid without blood, indicating a non-bloody exudate. It does not match the description of watery red drainage.
D. Purulent drainage is thick, opaque, and often yellow, green, or brown due to the presence of pus and infection. It does not apply here as the drainage is described as watery red.
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