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.
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Correct Answer is A
Explanation
Rationale:
A. Clients receiving continuous bladder irrigation after a transurethral resection of the prostate (TURP) often feel a constant urge to void due to the presence of the catheter and the irrigation fluid in the bladder. The nurse should reassure the client that this sensation is expected.
B. Weighing the client is not necessary for immediate postoperative care following TURP. Fluid balance is managed by monitoring urine output rather than daily weight.
C. Urine output should be monitored more frequently than every 6 hours in the immediate postoperative period, especially with continuous bladder irrigation, to ensure there are no blockages or complications.
D. Fluid restriction is not recommended after TURP. In fact, encouraging oral fluid intake helps maintain hydration and prevents blood clots in the bladder irrigation system.
Correct Answer is A
Explanation
Rationale:
A. Serous drainage is clear and watery, which is typical during the early stages of healing and indicates normal wound healing.
B. Purulent drainage is thick and may appear yellow, green, or brown, indicating infection.
C. Serosanguineous drainage is a mix of serous fluid and small amounts of blood, typically pink in color, and is seen in wounds that are healing.
D. Sanguineous drainage is primarily blood, indicating fresh bleeding from a wound.