A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)
A client who has right-sided heart failure and 4+ edema to the lower extremities
A client who is ambulatory following a cardiac catheterization 4 hr ago
A client who has type 1 diabetes mellitus and is hyperglycemic
A client who has protein calorie malnutrition
A client who has postoperative delirium
Correct Answer : A,C,D,E
Rationale:
A. A client with right-sided heart failure and 4+ edema is at risk for pressure ulcers due to fluid accumulation, which can impair circulation and increase the likelihood of skin breakdown.
B. A client who is ambulatory is at a low risk for pressure ulcers because frequent movement reduces the risk of prolonged pressure on any one area.
C. A client with type 1 diabetes mellitus and hyperglycemia is at risk for pressure ulcers because high blood glucose levels can impair wound healing and affect skin integrity.
D. A client with protein-calorie malnutrition is at a significant risk for pressure ulcers due to inadequate nutrition, which weakens the skin and impairs the body’s ability to repair tissue damage.
E. A client with postoperative delirium may have decreased mobility and cognitive awareness, making it harder for them to reposition themselves, thereby increasing their risk of pressure ulcers.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Rationale:
A. Emptying the pouch when it becomes 1/3 full is appropriate and helps prevent leakage and odor. This statement shows understanding of proper pouch management.
B. Enteric-coated medications can be problematic for clients with an ileostomy as they may not dissolve properly in the digestive system, potentially leading to decreased absorption. The client should be aware that these medications may not be suitable for their condition.
C. Changing the entire pouch system at least weekly is a common recommendation to maintain hygiene and skin integrity. This indicates the client understands the need for regular pouch maintenance.
D. Caution when eating high-fiber foods is important, as these foods can cause blockages in the ileostomy. This statement reflects the client’s awareness of dietary considerations for managing their ileostomy.
Correct Answer is B
Explanation
Rationale:
A. Changing the catheter once each shift is unnecessary and can increase the risk of infection. Catheters should be replaced only when clinically indicated.
B. Checking the catheter tubing for kinks or twisting is essential to ensure proper drainage and reduce the risk of infection. This action promotes unobstructed urine flow, which is critical for infection prevention.
C. Replacing the catheter every 3 days is not a standard practice; catheters should be changed based on clinical need rather than a set schedule. This could unnecessarily increase the risk of infection.
D. While cleaning the perineal area is important, using an antiseptic solution daily may cause irritation and disrupt the normal flora of the area. Routine cleaning with mild soap and water is typically recommended instead.