A client presents with a pressure ulcer and signs of infection. Which nursing action aligns with the information in the text?
"I'll consult with the healthcare team to address underlying medical conditions.".
"I'll encourage frequent position changes and mobility exercises.".
"I'll use specialized mattresses to offload pressure.".
"I'll provide education on proper wound care and prevention strategies.".
The Correct Answer is A
Choice A rationale:
Consulting with the healthcare team to address underlying medical conditions (Choice A) is the most appropriate nursing action for a client with a pressure ulcer and signs of infection.
Pressure ulcers can develop or worsen due to underlying medical conditions such as diabetes, vascular disease, or immunosuppression.
Addressing these underlying conditions is essential for effective wound management and preventing further complications.
Choice B rationale:
Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention to prevent pressure ulcers, but in a client with an existing pressure ulcer and signs of infection, addressing the infection and underlying medical conditions take precedence.
Choice C rationale:
Using specialized mattresses to offload pressure (Choice C) is an important part of pressure ulcer prevention and management, but it may not be the most immediate action needed for a client with signs of infection.
Addressing infection and underlying medical conditions (Choice A) should be the priority.
Choice D rationale:
Providing education on proper wound care and prevention strategies (Choice D) is an essential nursing action but may not be the most immediate priority for a client with an active infection.
Managing the infection and addressing underlying medical conditions (Choice A) should come first.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
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.
Correct Answer is A
Explanation
Choice A rationale:
The nurse is likely to observe warmth around the pressure ulcer site with intact skin.
This is a characteristic clinical manifestation of a stage 1 pressure ulcer.
In stage 1 pressure ulcers, there is non-blanchable erythema (redness) of the skin due to localized inflammation, and the area may feel warm to the touch.
However, the skin is still intact, and there are no open wounds or pus.
Choice B rationale:
This choice is incorrect because the patient described in the question has intact skin, and there is no mention of an open wound with pus.
Pus is typically associated with wound infection, which is not a feature of stage 1 pressure ulcers.
Choice C rationale:
The patient reporting a sharp pain in the affected area is not consistent with the characteristics of a stage 1 pressure ulcer.
Stage 1 pressure ulcers are typically not associated with pain because they only involve the superficial layers of the skin, and the underlying tissues are not affected.
Choice D rationale:
Swelling around the wound is not a typical clinical manifestation of a stage 1 pressure ulcer.
In stage 1, the skin may appear red and feel warm to the touch due to inflammation, but there is no mention of swelling in the question.
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