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 C
Explanation
A. The blood must be checked by two licensed professionals, not an assistant personal (AP).
B. Blood should be infused within 4 hours to reduce the risk of bacterial contamination.
C. The nurse should remain with the client for the first 15 minutes of the transfusion to monitor for any immediate adverse reactions.
D. Pre-medicating with an antiemetic is not a standard practice unless specifically indicated by the client's history or condition.
Correct Answer is A
Explanation
A. Rinsing the mouth after administration of an inhaled corticosteroid helps prevent oral thrush, a common side effect of these medications.
B. Limiting caffeine intake is not specifically necessary for the use of inhaled corticosteroids.
C. Taking the medication with meals is not required for inhaled corticosteroids.
D. Checking the pulse after administration is not necessary for inhaled corticosteroids.
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