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 B
Explanation
Rationale:
A. Applying cornstarch can absorb moisture; however, it may not be the most effective method to maintain skin integrity and can cause friction when applying.
B. A diet high in protein is essential for skin health and repair, as it supports tissue regeneration and helps prevent skin breakdown in vulnerable clients.
C. Massaging bony prominences is not recommended, as it may cause further tissue damage or disrupt circulation. Instead, padding and reducing pressure on these areas is more beneficial.
D. Repositioning the client every 3 hours may not be frequent enough for someone at high risk for skin breakdown; generally, repositioning should occur at least every 2 hours to alleviate pressure.
Correct Answer is A
Explanation
Rationale:
A. A significant drop in blood pressure from 138/86 mm Hg to 90/60 mm Hg indicates potential hypovolemia or hemorrhage, which requires immediate intervention to prevent shock or other complications. This is the most critical finding among the clients.
B. A client with stable blood glucose levels between 110 mg/dL and 100 mg/dL is not a priority, as these readings are within a normal range and do not indicate immediate danger.
C. The transition of wound drainage from sanguineous to serosanguineous is a normal part of the healing process and is not an urgent concern.
D. A mild increase in pain from 1 to 3 on a 1 to 10 scale is also not an immediate priority, as it remains within a low pain range and can be managed with routine pain control measures.