Nokea
Which client is at the highest risk for developing a decubitus ulcer among the following patients in a long-term care facility?
- A. An incontinent client who had 3 diarrheal stools
- B. An 80-year-old ambulatory diabetic client
- C. A 79-year-old malnourished client on bed rest
- D. An obese client who occasionally uses a wheelchair
Correct Answer: C
Rationale: The malnourished client on bed rest is at highest risk due to immobility and poor nutritional status, both major contributors to pressure ulcer development.
You may also like to solve these questions
The nurse is caring for a client with several severe pressure ulcers. Which laboratory result requires the nurse to intervene?
- A. Serum albumin level of 2.5 g/dL [3.5-5 g/dL]
- B. Serum potassium level of 4 mEq/L (mmol/L) [3.5 and 5.0 mEq/L (mmol/L)]
- C. Serum sodium level of 140 mEq/L (mmol/L) [135-145 mEq/L (mmol/L)]
- D. White blood cell count of 9,000 cells/uL (9x10%) [4,500-11,000 cells/uL, 3.5-10.5 × 10°/L]
Correct Answer: A
Rationale: A low serum albumin level (2.5 g/dL) indicates malnutrition, which impairs wound healing and requires intervention. Other lab values are within normal ranges.
The nurse is discussing how to provide foot care to clients to a group of unlicensed assistive personnel (UAPs). The nurse should reinforce that Select all that apply.
- A. mild soap and tepid water should be used
- B. the feet should be soaked in hot water and oil
- C. The feet should be dried thoroughly, as well as in between the toes
- D. an alcohol rub may be used if the feet appear dry
- E. scaling and discoloration of the feet should be reported to the nurse
- F. The toenails should be cut at the lateral corners when trimming the nails
Correct Answer: A, C, E
Rationale: Mild soap and tepid water, thorough drying, and reporting abnormalities are correct. Hot water, alcohol rubs, and cutting toenails at corners can cause injury or infection.
The nurse is providing discharge instructions to a client with a skin abscess that has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following instructions should the nurse include?
- A. Avoid using alcohol-based hand sanitizer
- B. Use disposable dishes and utensils for all meals
- C. Wear a surgical mask when you are out in public
- D. Keep the wound covered with a dry bandage
Correct Answer: D
Rationale: Keeping the wound covered with a dry bandage prevents the spread of MRSA and protects the wound from further contamination.
The ABCDEs of melanoma identification include which of the following? Select all that apply.
- A. Asymmetry: one half does not match the other half
- B. Birthmark: cafe au lait spot that does not fade
- C. Color: pigmentation is not uniform
- D. Diameter: greater than 6 mm
- E. Evolving: any change in size, shape, color, elevation, or any new symptom such as bleeding, itching, or crusting
Correct Answer: A, C, D, E
Rationale: The ABCDEs of melanoma are Asymmetry, Border (irregular), Color (varied), Diameter (>6 mm), and Evolving (changes in appearance or symptoms). Birthmark is not part of this mnemonic.
The wound care nurse is caring for a client at the outpatient clinic
Item 1 of 1
Nurses' Notes
Medical History
1300 - Client presents to the clinic on a referral from the primary healthcare provider for a wound to the right ankle area. The injury developed three months ago and has worsened despite topical treatment. On assessment, the wound is 5 cm x 4 cm and is shallow. The wound bed is pink with some granulation tissue; scant sanguineous drainage. Wound edges are uneven. Client reports pain only when dressing changes are performed, and the pain is rated as 5 on a scale of 0 (no pain) to 10 (severe pain). The surrounding skin on the affected foot is dry, darkened, and flaky. Capillary refill < 3 seconds. Peripheral pedal pulse 2+ on the affected foot. 3+ Ankle edema was noted in both lower extremities. The client denies leg pain during ambulation but endorses ankle swelling during the day while walking, and the only relieving factor is the application of a compression hose to both legs. The client reports applying a hot compress to the extremity but states after 2-3 applications, it worsened and became painful.
For each assessment finding below, click to specify if the finding is consistent with an arterial, venous, or diabetic ulcer. Each finding may support more than one (1) disease process.
- A. swelling in affected extremity
- B. pedal peripheral pulse 2+
- C. swelling relieved with compression hose
- D. denies leg pain during ambulation
- E. shallow wound bed
- F. medical history of hypertension and diabetes mellitus
- G. worsened with hot compress
Correct Answer: A: B, D, E, F; V: A, C, E; D: E, F, G
Rationale: Arterial ulcers: normal pulse, no leg pain, shallow wounds, and hypertension/diabetes history. Venous ulcers: swelling, compression relief, shallow wounds. Diabetic ulcers: shallow wounds, diabetes history, worsened with heat.