which client is at highest risk for developing a pressure ulcer

NCLEX-RN

NCLEX RN Practice Questions Exam Cram

1. Which client is at highest risk for developing a pressure ulcer?

A. 23 year-old in traction for fractured femur
B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
C. 75 year-old with left sided paresthesia and is incontinent of urine and stool
D. 30 year-old who is comatose following a ruptured aneurysm

Correct answer: C

Rationale: Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

2. Which of these clients is likely to receive sublingual morphine?

A. A 75-year-old woman in a hospice program
B. A 40-year-old man who just had throat surgery
C. A 20-year-old woman with trigeminal neuralgia
D. A 60-year-old man who has a painful incision

Correct answer: A

Rationale: The correct answer is a 75-year-old woman in a hospice program. Sublingual morphine is commonly used in hospice care because patients may have difficulty swallowing, and intravenous access can be uncomfortable and not ideal for palliative care. Choice B, a 40-year-old man who just had throat surgery, is less likely to receive sublingual morphine as he may be able to swallow, and other pain management options may be more suitable. Choice C, a 20-year-old woman with trigeminal neuralgia, would typically require specific medications targeting neuropathic pain rather than sublingual morphine. Choice D, a 60-year-old man with a painful incision, may benefit from localized pain relief or other systemic pain management options, but sublingual morphine is not usually the first choice for this type of pain.

3. The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?

A. Observe for distended neck veins.
B. Auscultate for crackles in the lungs.
C. Palpate for heaves or thrills over the heart.
D. Review hemoglobin and hematocrit values.

Correct answer: A

Rationale: To evaluate the effectiveness of therapies for cor pulmonale and right-sided heart failure, observing for distended neck veins would be the most appropriate assessment. Cor pulmonale is characterized by right ventricular failure due to pulmonary hypertension, leading to clinical manifestations such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness. These signs indicate increased central venous pressure and right heart strain, which can be assessed by observing for distended neck veins. Auscultating for crackles in the lungs is more indicative of left-sided heart failure rather than right-sided heart failure. Heaves or thrills over the heart are not typically associated with cor pulmonale. Reviewing hemoglobin and hematocrit values may show elevations due to chronic hypoxemia and polycythemia in cor pulmonale, but these values alone do not directly evaluate the immediate effectiveness of the prescribed therapies on the patient's condition.

4. The client is being prepared for insertion of a pulmonary artery catheter (Swan-Ganz catheter). What information does the client need to know about the purpose of this catheter insertion?

A. Stroke volume
B. Cardiac output
C. Venous pressure
D. Left ventricular functioning

Correct answer: D

Rationale: The correct answer is D: Left ventricular functioning. The purpose of inserting a pulmonary artery catheter is to obtain information about left ventricular functioning when the catheter balloon is inflated. Choices A, B, and C are incorrect because while a pulmonary artery catheter can provide information on stroke volume, cardiac output, and venous pressure, its primary purpose is to assess left ventricular function.

5. The child with hemolytic-uremic syndrome is anuric and will undergo peritoneal dialysis. Which measure should the nurse implement?

A. Restrict fluids as prescribed.
B. Care for the arteriovenous fistula.
C. Encourage foods high in potassium.
D. Administer analgesics as prescribed.

Correct answer: A

Rationale: In hemolytic-uremic syndrome, often associated with bacterial toxins and viruses, acute kidney injury occurs in children, leading to symptoms like anemia, thrombocytopenia, renal injury, and CNS symptoms. For an anuric child with hemolytic-uremic syndrome undergoing peritoneal dialysis, fluid restriction is vital to prevent fluid overload. Pain management is not directly related to hemolytic-uremic syndrome. Foods high in potassium should be limited, not encouraged, due to impaired kidney function. Peritoneal dialysis does not involve an arteriovenous fistula, which is specific to hemodialysis.