A chronically ill, bedfast patient cared for in the home by family members has a stage II pressure ulcer over the coccyx. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to
Provide the patient with a high-calorie, high-protein diet.
Change the patient's position every 2 hours, avoiding the supine position.
Change the patient's linen daily.
Record the size and appearance of the ulcer daily.
The Correct Answer is B
A. While a high-calorie, high-protein diet is beneficial for wound healing, it is not the most critical factor in preventing further tissue damage.
B. Changing the patient's position every 2 hours is crucial to relieve pressure on the ulcer and prevent further tissue damage.
C. Changing the patient's linen daily is important for hygiene but does not directly prevent pressure ulcer progression.
D. Recording the size and appearance of the ulcer is important for monitoring, but preventing further damage through repositioning is more critical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Grilled salmon is high in protein and also provides omega-3 fatty acids, which are beneficial for wound healing.
B. Kidney beans are a good source of protein but not as high as salmon.
C. Raw spinach is nutritious but low in protein.
D. Peanut butter contains protein, but not as much as salmon and may not be as easily digestible for some patients.
Correct Answer is B
Explanation
A. Enteral feeding, while important, can wait momentarily if the client's airway needs immediate attention.
B. Endotracheal suctioning is a priority if the client is having difficulty breathing or has excessive secretions in the airway.
C. Wound irrigation can be performed after ensuring the client's airway is clear and stable.
D. Urinary catheter care is important but can be prioritized after addressing acute respiratory needs.
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