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 D
Explanation
A. Hepatitis screening typically involves blood tests.
B. Meningitis is diagnosed through lumbar puncture and laboratory tests, not intradermal injection.
C. Diabetes screening involves blood glucose testing, not intradermal injection.
D. Tuberculosis (TB) screening is commonly performed using an intradermal injection, known as the Mantoux tuberculin skin test.
Correct Answer is D
Explanation
A. It is not accurate to say it is never permissible; some herbal supplements may be safely used with certain medications under professional guidance.
B. Herbs can have pharmacologic effects and may interact with prescription medications, even if they are not classified as drugs in the U.S.
C. Referring to an herbalist is not the best immediate response; the nurse should first address potential interactions and safety concerns.
D. Herbs can indeed have pharmacologic effects and interact with prescription medications, potentially causing adverse effects or altering the effectiveness of the medications.
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