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.

Answer and Explanation

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.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

This choice is not correct because verifying the oxygen flow rate every other day is not part of the discharge teaching for a client on home oxygen therapy. The flow rate should be checked regularly, not just every other day, to ensure the client's safety and well-being.

Choice B rationale:

This choice is correct. Checking the tops of the ears for skin breakdown is important in a client using a nasal cannula for oxygen therapy. Prolonged use of the cannula can lead to irritation and pressure-related skin breakdown behind the ears.

Choice C rationale:

This choice is correct. Posting "no smoking signs in a prominent location in the home" is an important safety measure for a client on oxygen therapy. Oxygen supports combustion, and smoking in the presence of oxygen can lead to fire hazards.

Choice D rationale:

This choice is correct. Checking the cannula position on a regular basis is essential to ensure that the oxygen is being delivered effectively and that the client is not experiencing discomfort or skin breakdown due to improper positioning.

Choice E rationale:

This choice is correct. Applying petroleum ointment to the nares if they become dry and irritated is a suitable intervention to maintain the client's comfort and prevent skin irritation from the cannula.

A. Only fresh frozen plasma should be transfused to the client. B. An immediate blood transfusion should be started due to the client's condition. C. The client should be asked to decide about the blood transfusion. D. The client's family should be notified immediately of the situation.

Correct Answer is C

Explanation

Choice A rationale:

Fresh frozen plasma (FFP) is a component of blood used to replace clotting factors and is typically indicated for specific medical conditions like bleeding disorders or massive transfusions. In this case, the client requires red blood cells due to significant blood loss, so FFP alone is not the appropriate choice.

Choice B rationale:

Initiating an immediate blood transfusion without the client's consent is not ethically appropriate, especially considering the client's religious beliefs as a Jehovah's Witness. Respecting the client's autonomy and religious convictions is important.

Choice C rationale:

Asking the client to decide about the blood transfusion is the correct course of action. Since the client is able to respond to questions appropriately, they should be informed about their condition, the need for a blood transfusion, and the potential risks and benefits. This respects the client's autonomy while ensuring they have the necessary information to make an informed decision.

Choice D rationale:

Notifying the client's family immediately is not the best initial action. While involving the family is important, the client's own decision about the blood transfusion should take precedence, especially when they are conscious and able to make decisions for themselves.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply.).

Correct Answer is ["B","C","D","E"]

Explanation

Correct Answer is C

Explanation

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