NCLEX-PN

Category - Reduction of Risk

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The nurse is reviewing the records of the assigned clients during the shift. Which of the following clients has the greatest risk for pressure ulcers?

A female client who has a BMI of 30
A postpartum client ambulating a day after giving birth
A client with an albumin level of 2.5 g/dL
An immobile client who is turned at least once every 2 hours

Explanation

Answer: C - Clients who are malnourished or deficient in protein have greater risk for pressure ulcers and wound infection. Protein is a nutrient needed for tissue damage repair. A client with a BMI of 30 is not at elevated risk. Early ambulation and turning every 2 hours minimize the risk for pressure ulcer.

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