Result Pressure Injury Question & Answer Guide (With Explanation)
Students often encounter this when studying fundamental concepts.
What This Question Is About
This question relates to result pressure injury and requires a structured academic response.
How to Approach This Question
Structure your response with introduction, analysis, and conclusion.
Key Explanation
This topic involves result pressure injury. A strong answer should include explanation, application, and examples.
Original Question
as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan? A Loosen the client’s bed linens. Question 33 of 62 : Score: 0% (0/62 Done) A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take? D Open the outermost flap of the sterile kit toward the body. Question 34 of 62 : Score: 0% (0/62 Done) A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect? A Eyelashes that curl slightly outward. Question 35 of 62 : Score: 0% (0/62 Done) A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take? A Wear clean gloves while cleaning the inner cannula. Question 36 of 62 : Score: 0% (0/62 Done) A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching? C “I will leave a light on in my bathroom at night.” Question 37 of 62 : Score: 0% (0/62 Done) A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence? C A nurse administers a medication without first identifying the client. Question 38 of 62 : Score: 0% (0/62 Done) A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect? A Eyelashes that curl slightly outward. Eyelashes that curl slightly outward is a normal finding. Question 39 of 62 : Score: 0% (0/62 Done) A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make? C “I will repeat these movements 3 to 5 times.” Question 40 of 62 : Score: 0% (0/62 Done) A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care? B Use trochanter rolls beside the client’s legs. Question 41 of 62 : Score: 0% (0/62 Done) A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication? A A sharp decrease in blood pressure Question 42 of 62 : Score: 0% (1/62 Done) A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A Assess skin temperature and color before applying the restraints. Assessing skin temperature and color is crucial to ensure circulation and skin integrity before applying restraints. C Ensure that the client’s bed is in the lowest position. Ensuring the client’s bed is in the lowest position is essential to prevent falls and reduce the risk of injury if the client attempts to leave the bed. D Pad bony prominences before applying the restraints. Question 43 of 62 : Score: 0% (1/62 Done) A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching? . C “I will leave a light on in my bathroom at night.” Question 44 of 62 : Score: 0% (1/62 Done) A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first? D Endotracheal suctioning Question 45 of 62 : Score: 0% (1/62 Done) A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client’s room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first? C Gloves Question 46 of 62 : Score: 0% (1/62 Done) A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use? D Three-point gait Question 47 of 62 : Score: 0% (1/62 Done) A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make? D “We can discuss what you can expect during your stay.” A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include? B Weight Question 49 of 62 : Score: 0% (1/62 Done) A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client’s BP is 158/96 mm Hg. Which of the following actions should the nurse take? A Ensure that the width of the BP cuff is 50% of the client’s upper arm circumference. Question 50 of 62 : Score: 0% (1/62 Done) To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning? C Client care provider Question 51 of 62 : Score: 0% (1/62 Done) A nurse manager overhears a nurse telling a client, “I will administer your medication by injection if you don’t swallow your pills.” The nurse manager should identify that the nurse is committing which of the following torts? A Assault Question 52 of 62 : Score: 0% (1/62 Done) A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to Include? A Assist the client with a bowel cleansing Question 53 of 62 : Score: 0% (1/62 Done) A nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take? A Roll the client as one unit in a smooth, continuous motion. A nurse is obtaining a health history from a client. Which of the following factors places the client at risk for cardiovascular disease? A Metabolic syndrome Question 55 of 62 : Score: 0% (1/62 Done) A nurse is conducting the Weber’s test on a client. Which of the following is an appropriate action for the nurse to take? B Place an activated tuning fork in the middle of the client’s forehead. A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse? C “You’re concerned about what will happen when you leave the hospital.” Question 57 of 62 : Score: 0% (1/62 Done) A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client’s risk of developing a pressure injury? B Ensure the client’s heels are not touching the mattress. Question 58 of 62 : Score: 0% (2/62 Done) A nurse is caring for a client who has pneumonia. Nurses’ Notes Day 1, 1100: Client admitted from emergency department with a new diagnosis of pneumonia. Confirmed by chest x-ray and laboratory results. Reports dyspnea and exhibits shortness of breath at rest. Client is hypoxic, confirmed by oxygen saturation. Placed on oxygen at 2 U/min via nasal cannula. Congested cough, sputum specimen obtained and sent to the laboratory. Crackles heard on auscultation; breath sounds diminished. IV initiated in left forearm with 22-gauge anglo-catheter for intermittent antibiotic therapy and further treatment. Day 2, 1500: Client remains hypoxic. Less dyspnea noted at rest, extreme shortness of breath noted on exertion. Receiving intermittent IV medications. IV site without manifestations of infection or infiltration. Vital Signs Day 1, 1100: Temperature 39.1° C (102.4° F) Pulse rate 102/min Respiratory rate 26/min Blood pressure 122/80 mm Hg Oxygen saturation 86% on room air Weight 90.7 kg (200 lb) Day 2, 1200: Temperature 38° C (100.4″ F) Pulse rate 100/min Respiratory rate 22/min Blood pressure 120/74 mm Hg Oxygen saturation 88% on nasal cannula at 2 L/min Day 3, 1200: Temperature 37.2° C (98.9″ F) Pulse rate 90/min Respiratory rate 20/min Blood pressure 120/72 mm Hg Oxygen saturation 91% on nasal cannula at 3 L/min Day 4, 1500: Temperature 37.2° C (98.9° F) Pulse rate 92/min Respiratory rate 22/min Blood pressure 120/72 mm Hg Oxygen saturation 93% on nasal cannula at 3 L/min: 88% on room air Medication Administration Record Day 1, 1500: Cefazolin 500 mg every 12 hr IV Dexamethasone 15 mg every 6 hr IV Day 3, 1200: Discontinue dexamethasone 15 mg every 6 hr IV Prednisone 40 mg PO daily Day 4, 1500: Discontinue cefazolin 500 mg every 12 hr IV The nurse is providing discharge teaching for the client and their caregiver. Which of the following information should the nurse include? Select all that apply. A Adjust the oxygen flow rate as needed to ease breathing. C Store the oxygen cylinder wrench with the oxygen tank. D Ensure the oxygen delivery system is at least 8 feet from any heat source. E Steroid medication should be taken in the morning. Question 59 of 62 : Score: 0% (3/62 Done) A nurse is caring for a client who is scheduled for surgery. Diagnostic Results 1000: Prealbumin level 13 mg/dL (15 to 36 mg/dL) Cholesterol 210 mg/dL (less than 200 mg/dL) Fasting glucose 110 mg/dL (70 to 110 mg/dL) Medical History 0800: The client has a history of malnutrition, hyperlipidemia, and diabetes mellitus. Mini Nutritional Assessment screening tool score of 7 points (0 to 14 points) The nurse is reviewing the client’s medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply. C History of malnutrition D History of diabetes mellitus F Prealbumin level Question 60 of 62 : Score: 0% (4/62 Done) A nurse in a provider’s office is caring for a client. Medical History Initial visit: Client reports a sedentary lifestyle. Client is lactose intolerant and denies taking vitamin supplements. Client is a nonsmoker. Client does not drink alcohol. Diagnostic Results Initial visit: Calcium 8.9 mg/dL (9 to 10.5 mg/dL) Phosphorus 3.4 mg/dL (3 to 4.5 mg/dL) Total 25-hydroxy D (vitamin D2+ D3) 24 ng/dL (25 to 80 ng/dL) 6-month follow-up: Calcium 8.8 mg/dL (9 to 10.5 mg/dL) Phosphorus 3.2 mg/dL (3 to 4.5 mg/dL) Total 25-hydroxy D (vitamin D2+D) 15 ng/dL (25 to 80 ng/dL) Nurses’ Notes Initial visit: Client instructed to take a calcium and vitamin D supplement and begin an exercise program, such as walking 3 times per week. 6-month follow-up: Client states they frequently forget to take their calcium and vitamin D supplements and has been unable to exercise due to time constraints. The nurse is reviewing the client’s medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.) C Vitamin D level F Activity level Question 61 of 62 : Score: 0% (5/62 Done) A nurse is caring for a client. Vital Signs 0800: Temperature 37.6° C (99.7 F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min Pulse oximetry 97% on room air 0830: Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min Pulse oximetry 93% on room air Nurses’ Notes 0800: Antibiotic administered as prescribed. Bilateral breath sounds clear and present throughout. 0830 Client reports itching over the chest area and has urticaria over chest and trunk. Client states tongue feels swollen Bilateral breath sounds with scattered wheezing upon auscultation, Select the 4 findings that require immediate follow-up. B Blood pressure D Urticaria E Swollen tongue F Breath sounds Question 62 of 62 : Score: 0% (6/62 Done) A nurse is caring for a client who is scheduled for a surgical procedure. Medical History 2 days before procedure: Client takes 80 mg of aspirin PO daily for antiplatelet effects. Client performs moderate intensity exercise for 150 min each week. Client reports an allergy to latex. Nurses’ Notes Morning of procedure: Client reports taking aspirin 80 mg PO this morning with a sip of water. Diagnostic Results Hct 37% (37% to 47%) Hgb 12 g/dL (12 to 16 g/dL) WBC count 12,000/mm3 (5,000 to 10,000/mm3) Prothrombin time 21 seconds (11 to 12.5 seconds) Select the 4 findings that require immediate follow-up.
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