A nurse is assisting with developing a plan of care for a client.
Exhibit 1
Nurses' Notes
2 days ago:
Client admitted to telemetry unit for uncontrolled atrial fibrillation. Admission skin assessment, area of intact, blanchable skin on client's coccyx.
Today, 0900:
Wound on client's coccyx no longer covered with intact skin. Wound involves full-thickness skin loss, shallow depth with no tunneling. New granulation noted. Minimal amount of exudate noted. Client reports wound pain as 5 on a scale of 0 to 10 and is unable to find a comfortable position.
Complete the following sentence by using the lists of options.
The nurse understands that which of the following dressing should be added to the plan of care Select...
hydrocolloid
dry gauze
hydrogel
alginate
transparent
Correct Answer : A
A. A hydrocolloid dressing is a type of dressing that is used for wounds with minimal exudate, such as the wound on the client's coccyx described in the scenario. It provides a moist environment for wound healing and can help with pain relief. This type of dressing is suitable for wounds with granulation tissue and can help protect the wound from further damage while promoting healing.
B. A dry gauze is not appropriate for this type of wound as it does not provide the necessary moist environment for healing and may adhere to the wound, causing damage upon removal.
C. A hydrogel dressing is typically used for wounds with moderate to heavy exudate.
D. An alginate dressing is typically used for wounds with moderate to heavy exudate. These dressings may not be suitable for the described wound with minimal exudate.
E. A transparent dressing may not be suitable for a wound with granulation tissue and moderate exudate, as it may not provide adequate protection and moisture to the wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. While the client's feelings about never marrying are important, they do not represent an immediate health risk or safety concern.
B. Poorly fitting dentures can affect the client's quality of life and ability to eat, but they do not represent an immediate health risk or safety concern.
C. While having no living family can be a social concern, it does not represent an immediate health risk or safety concern.
D. The client being sedentary throughout most of the day is a risk factor for numerous health problems, including cardiovascular disease, obesity, and decreased mobility. It is also a modifiable risk factor that can be addressed to improve the client's health and quality of life. Encouraging the client to engage in regular physical activity is a priority.
Correct Answer is ["B","E"]
Explanation
A. Squeezing the client's finger can cause hemolysis and affect test accuracy.
B. Pricking the side of the finger is recommended because it is less painful and provides better blood flow.
C. Keeping the hand below heart level promotes better blood flow; elevating it can reduce blood flow.
D. Alcohol is preferred for cleansing; iodine can interfere with test results.
E. Wearing clean gloves is necessary for infection control and safety.
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