A Medical-Surgical nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?
Clean the wound by scrubbing the site with gauze.
Massage reddened areas with dressing changes.
Reposition the client at least every 2 hours.
Apply a heat lamp twice a day.
The Correct Answer is C
Choice A rationale:
Cleaning the wound by scrubbing the site with gauze is not an appropriate intervention for a stage 3 pressure ulcer. Scrubbing can damage the fragile tissue, increase the risk of infection, and delay wound healing. Gentle cleaning with a mild solution and avoiding trauma to the wound bed are recommended.
Choice B rationale:
Massaging reddened areas with dressing changes is contraindicated for pressure ulcers, especially stage 3 ulcers. Massaging can cause further damage to the tissues and disrupt the healing process. Dressing changes should focus on maintaining a clean and moist environment to promote healing.
Choice C rationale:
(Correct Choice) Repositioning the client at least every 2 hours is a crucial intervention to prevent further pressure ulcers and facilitate wound healing. Regular repositioning helps relieve pressure on specific areas and improves blood circulation, reducing the risk of tissue breakdown and the development of new ulcers.
Choice D rationale:
Applying a heat lamp twice a day is not recommended for stage 3 pressure ulcers. Heat can increase blood flow to the area, potentially exacerbating inflammation and delaying healing. Pressure ulcers require a clean and moist environment for optimal healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Instructing the client not to adjust the oxygen flow rate is crucial to ensure the appropriate amount of oxygen is delivered. Oxygen flow rates are prescribed by a healthcare provider based on the client's needs, and altering the flow rate without medical guidance can lead to inadequate oxygen delivery or oxygen toxicity.
Choice B rationale:
Weekly equipment checks are important, but this choice is not the most critical instruction. Clients should be instructed to check their oxygen equipment daily for proper functioning and to address any issues promptly. Waiting a whole week could lead to potential problems going unnoticed.
Choice C rationale:
Storing unused oxygen tanks horizontally is incorrect. Oxygen tanks should be stored upright to prevent leaks and ensure proper functioning. Storing them horizontally can cause valve damage and leakage, which could lead to hazards.
Choice D rationale:
Using wool blankets on the bed is not a suitable instruction for a client using oxygen therapy. Wool blankets can generate static electricity, which might pose a fire hazard in the presence of oxygen-enriched environments.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Dyspnea (shortness of breath) is a common finding in clients with emphysema. Emphysema is a chronic obstructive pulmonary disease characterized by the destruction of lung tissue, leading to reduced lung elasticity and airflow limitation, which can result in difficulty breathing.
Choice B rationale:
Clubbing of the fingers is another expected finding in clients with advanced emphysema. Clubbing is the swelling and rounding of the fingertips, often associated with chronic respiratory conditions. It is thought to be a result of chronic hypoxia and inadequate oxygenation.
Choice C rationale:
Deep respirations are not typically associated with emphysema. Clients with emphysema often exhibit shallow, rapid respirations due to the loss of lung tissue elasticity, which impairs the normal respiratory mechanics.
Choice D rationale:
Bradycardia (slow heart rate) is not a common finding in emphysema. Emphysema primarily affects the respiratory system and does not directly influence heart rate. Bradycardia could be related to other factors but is not a characteristic finding of emphysema.
Choice E rationale:
Barrel chest is a classic physical finding in clients with emphysema. It results from the hyperinflation of the lungs due to the trapping of air in the damaged alveoli. This gives the chest a rounded appearance, similar to the shape of a barrel.
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