Nokea
A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?
- A. BMI of 20
- B. Peripheral neuropathy
- C. Immobility
- D. Hypoperfusion
- E. Prealbumin level of 16 mg/dL
Correct Answer: B,C,D,E
Rationale: B: Neuropathy reduces sensation. C: Immobility causes prolonged pressure. D: Hypoperfusion impairs tissue oxygenation. E: Low prealbumin indicates poor nutrition.
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A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?
- A. Withhold the feeding if the residual volume is 150 mL
- B. Flush the tube with 30 mL of sterile water before the feeding
- C. Cleanse the top of the can of formula with an alcohol wipe
- D. Keep the formula cold until instillation
Correct Answer: B
Rationale: Flushing with 30 mL of sterile water ensures tube patency and prevents clogging before feeding.
A nurse is reinforcing teaching about informed consent with a newly licensed nurse. Which of the following should be included as a responsibility of the nurse in this process?
- A. Discuss the risks of the procedure with the client.
- B. Confirm that the client is competent to sign for the procedure.
- C. Explain alternatives to the procedure to the client.
- D. Inform the client about what will occur during the procedure.
Correct Answer: B
Rationale: The nurse ensures the client's competence to consent, while the physician explains risks and procedures.
A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
- A. Increased collagen
- B. Increased muscle mass
- C. Decreased serum calcium
- D. Decreased circulation
Correct Answer: D
Rationale: Decreased circulation from immobility reduces tissue oxygenation, increasing pressure injury risk.
A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
- A. Partial-thickness skin loss with red tissue in the wound bed.
- B. Intact skin with localized erythema.
- C. Full-thickness skin loss with visible adipose tissue.
- D. Full-thickness skin loss with visible bone.
Correct Answer: A
Rationale: Stage 2 pressure injuries show partial-thickness loss with a red wound bed, indicating damage to epidermis and possibly dermis.
A nurse is contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings?
- A. Hypoglycemia
- B. Fluid volume overload
- C. Dermatitis
- D. Kidney stones
Correct Answer: C
Rationale: Dermatitis results from prolonged moisture exposure in incontinence, risking skin breakdown.