After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching?

Correct Answer: B

Rationale: Correct Answer: B - High-protein diet with vitamins and mineral supplements Rationale: 1. High-protein diet aids in tissue repair and wound healing, crucial for preventing pressure ulcer formation. 2. Vitamins and mineral supplements support overall nutritional status, essential for skin integrity and healing. 3. Protein is vital for maintaining muscle mass, which helps prevent pressure ulcers. 4. Focusing on protein and essential nutrients is key for overall health and immune function. Summary of other choices: A: Low-fat diet may lack essential nutrients for wound healing. Vitamin supplements alone may not provide adequate protein for tissue repair. C: A vegetarian diet can be nutritious, but fish oil may not be sufficient for protein needs. Nutritional supplements may not provide enough protein. D: Low-fat, low-cholesterol, high-fiber, low-carb diet may lack adequate protein for tissue repair and wound healing.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Keeping water temperature constant is crucial to prevent burns or discomfort during hydrotherapy. 2. UAPs do not have the training to assess wound beds accurately; this falls under the nurse's scope of practice. 3. Applying a topical enzyme agent requires assessment and judgment beyond UAP's scope. 4. Using sterile saline for wound irrigation is a nursing task that should not be delegated to a UAP.

Correct Answer: A

Rationale: The correct answer is A because administering patch testing is a technical task that an LPN/LVN is qualified to perform. LPNs/LVNs are trained in basic patient care and medication administration. Patch testing involves applying allergens to a patient's skin to determine allergic reactions. This task does not require advanced assessment or critical thinking skills. Choice B involves interviewing a new patient about chronic health problems and allergies, which requires comprehensive assessment and critical thinking abilities typically performed by a registered nurse (RN). Choice C involves applying a sterile dressing after a medical procedure, which requires a higher level of assessment and critical thinking beyond the scope of an LPN/LVN. Choice D involves patient education after a medical procedure, which also requires a more advanced level of nursing assessment and critical thinking typically performed by an RN.

Correct Answer: D

Rationale: The correct answer is D because pale and cold skin around the incision indicates poor circulation and potential compromised blood flow, which could lead to tissue damage or necrosis. This is a critical finding that requires immediate attention to prevent further complications. A: Incisional pain is expected postoperatively and can be managed with pain medication, it does not indicate an immediate need for intervention. B: Heart rate elevation can be a normal response to surgery and anesthesia, and 110 beats/minute may not be concerning depending on the patient's baseline and clinical context. C: Temporary loss of sensation or numbness around the incision site is common after blepharoplasty due to local anesthesia effects, and it usually resolves as the anesthesia wears off. It does not require immediate intervention unless it persists or worsens.

Correct Answer: D

Rationale: The correct answer is D because a pressure ulcer worsening is indicated by progression to deeper tissue layers, such as the subcutaneous layer, and presence of drainage. This suggests tissue damage and increased risk of infection. Choice A describes an area of erythema that does not blanch, indicating possible skin damage but not necessarily worsening of the pressure ulcer. Choice B describes a blister, which can be a sign of pressure injury but does not necessarily indicate worsening. Choice C mentions intact skin and pain, which may suggest other issues but not necessarily worsening of the pressure ulcer.