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
Explanation
Rationale:
A. Clamping the tube when going for a walk is not recommended because it can cause urine to back up into the bladder.
B. Keeping the drainage bag below the level of the waist is recommended to prevent reflux of urine and reduce the risk of infection.
C. Emptying the drainage bag once a day may not be frequent enough to prevent urinary stasis and infection.
D. Applying antiseptic ointment to the tip of the penis is not recommended because it can cause irritation and discomfort.
Correct Answer is C
Explanation
Rationale:
A. Providing the client with three large meals each day may be overwhelming and may not promote an increase in food intake.
B. Limiting snacks between meals may not promote an increase in food intake and may contribute to malnutrition.
C. Providing the client with finger foods for meals is a practical approach that can promote an increase in food intake and reduce the risk of malnutrition.
D. Restricting visitors during meals may not promote an increase in food intake and may contribute to social isolation.
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