A client has developed cellulitis as a complication of a pressure ulcer. What action should the nurse prioritize according to the information provided in the text?
"I'll assess the patient's pain level and provide appropriate pain management.".
"I'll encourage frequent position changes and mobility exercises.".
"I'll administer antibiotics to treat the infection.".
"I'll optimize the patient's nutrition and hydration.".
The Correct Answer is C
Choice A rationale:
Assessing the patient's pain level and providing appropriate pain management (Choice A) is important for a patient with cellulitis as a complication of a pressure ulcer.
However, the immediate priority should be to treat the underlying infection with antibiotics (Choice C).
Pain management can be addressed after initiating antibiotic therapy.
Choice B rationale:
Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention for preventing pressure ulcers but may not be the most immediate action needed for a patient with cellulitis.
Treating the infection with antibiotics (Choice C) takes precedence.
Choice C rationale:
Administering antibiotics to treat the infection (Choice C) is the most appropriate nursing action for a client with cellulitis as a complication of a pressure ulcer.
Cellulitis is a bacterial infection that requires prompt antibiotic treatment to prevent its spread and complications.
Choice D rationale:
Optimizing the patient's nutrition and hydration (Choice D) is essential for overall health and wound healing, but in the context of cellulitis, treating the infection (Choice C) is the primary concern.
Once the infection is under control, nutritional support can be addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
"Advanced age is the primary risk factor for pressure ulcers in individuals with diabetes." While advanced age is a risk factor for pressure ulcers, it is not the primary risk factor in individuals with diabetes.
Diabetes itself presents several risk factors, including compromised blood flow and oxygenation, which increase the susceptibility to pressure ulcers.
Choice B rationale:
"Sensory deficits in diabetes make patients more resistant to pressure ulcers." This statement is incorrect.
Sensory deficits in diabetes, such as neuropathy, make patients more vulnerable to pressure ulcers.
These deficits can lead to reduced awareness of discomfort or pain, allowing pressure to be applied to areas without the patient's awareness.
Choice C rationale:
"Poor nutrition and hydration do not contribute to the development of pressure ulcers in diabetic patients." This statement is not accurate.
Poor nutrition and hydration can significantly contribute to the development of pressure ulcers in diabetic patients.
Adequate nutrition and hydration are essential for maintaining skin integrity and supporting the healing process.
Choice D rationale:
"Individuals with diabetes are more prone to pressure ulcers due to compromised blood flow and oxygenation." This statement is correct.
Diabetes can lead to compromised blood flow (peripheral vascular disease) and oxygenation (due to vascular damage), making individuals with diabetes more prone to pressure ulcers.
Correct Answer is C
Explanation
Choice A rationale:
"Pressure ulcers occur due to excessive friction on the skin." This statement is not accurate.
While friction can contribute to the development of pressure ulcers, it is not the primary pathophysiological factor.
Pressure ulcers primarily result from tissue ischemia and hypoxia, as well as pressure on the skin and underlying tissues.
Choice B rationale:
"Damage to the skin and underlying tissues in pressure ulcers is primarily caused by a lack of proper hygiene." Hygiene is essential in preventing pressure ulcers, but it is not the primary cause of their development.
Pressure ulcers are mainly caused by sustained pressure on bony prominences, leading to reduced blood flow and oxygenation to the affected area.
Choice C rationale:
"Ischemia and tissue hypoxia play a significant role in the development of pressure ulcers." This statement is correct.
Ischemia (reduced blood flow) and tissue hypoxia (inadequate oxygen supply) are key pathophysiological factors in the development of pressure ulcers.
Prolonged pressure on the skin and tissues leads to compromised blood flow, tissue damage, and ultimately, pressure ulcer formation.
Choice D rationale:
"Pressure ulcers result from a hyperactive immune response in the affected area." This statement is not accurate.
Pressure ulcers are not primarily caused by a hyperactive immune response.
While inflammation may occur in response to tissue damage, it is not the root cause of pressure ulcers.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.