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 ["B","D"]
Explanation
A. The client is already on a daily dose of Metoprolol, and there is no indication that the dose should be increased. In fact, it is important to monitor the client's blood pressure and heart rate closely due to the potential side effects of Metoprolol.
B. This is the appropriate action since the client is allergic to penicillin, and the prescription for amoxicillin should be reviewed with the provider.
C. There is no indication from the information provided that the client requires a surgical mask when outside their room.
D. The client has been vomiting and experiencing abdominal cramping, which suggests nausea and discomfort. Requesting a prescription for an antiemetic medication is an appropriate action to address these symptoms.
E. There is no indication from the information provided that the client requires contact precautions. The client has a urinary tract infection and is not exhibiting symptoms consistent with a condition that requires contact precautions.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
A. Despite the client reporting thirst and frequent urination, the client's urine specific gravity of 1.010 is within the normal range (1.005 to 1.030). The above symptoms could be associated with the hyperglycemia.
B. There is no indication of a pneumothorax in the nurse's notes or diagnostic results.
C. The casual glucose level of 300 mg/dL is significantly above the normal range (less than 200 mg/dL), indicating hyperglycemia.
D. The client’s WBC level is elevated, 11,500/mm3 (5,000 to 10,000/mm3) thus indicating an infection.
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