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 C
Explanation
A. Applying lidocaine gel to the urethra may provide additional lubrication but does not address the immediate issue of resistance during catheter insertion.
B. Inflating the catheter's balloon is inappropriate at this stage, as the catheter is not properly positioned for urine flow, and doing so could cause injury.
C. Lowering the penis to a 45° angle helps to straighten the urethra and can facilitate easier passage of the catheter, making it the most appropriate action.
D. Twisting the catheter gently is not recommended, as this may cause trauma to the urethra or increase discomfort without resolving the resistance issue.
Correct Answer is D
Explanation
Rationale:
A. Bowling is a low-impact activity that may not provide the weight-bearing exercise needed to help prevent osteoporosis.
B. Jogging is a high-impact activity that may not be appropriate for an older adult at risk for osteoporosis due to the potential for joint and bone stress.
C. Passive range-of-motion exercises are not weight-bearing and may not provide the same benefits as weight-bearing exercise.
D. Walking is a weight-bearing exercise that can help to increase bone density and reduce the risk of osteoporosis.
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