A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Transparent dressing.

Alginate dressing.

Hydrogel dressing.

Wet-to-dry gauze dressing.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Transparent dressing.

Choice A rationale:

Transparent dressings are appropriate for stage I pressure ulcers. These dressings provide a moist environment that promotes healing and protects the wound from external contaminants. They are also transparent, allowing the nurse to monitor the wound without removing the dressing. As stage I pressure ulcers involve intact skin with non-blanchable redness, these dressings aid in preventing friction and shear forces that could exacerbate the injury.

Choice B rationale:

Alginate dressings (Choice B) are not suitable for stage I pressure ulcers. Alginate dressings are highly absorbent and are generally used for wounds with moderate to heavy exudate, such as infected wounds or those with necrotic tissue. They may not be the best choice for a stage I pressure ulcer, which is characterized by superficial skin involvement without exudate or necrosis.

Choice C rationale:

Hydrogel dressings (Choice C) are beneficial for wounds with minimal to no exudate, but they are more appropriate for partial-thickness wounds, burns, or dry wounds. They provide a moist environment and promote autolytic debridement. However, in the case of a stage I pressure ulcer, where the skin is intact and there is no exudate, hydrogel dressings may not be the ideal choice.

Choice D rationale:

Wet-to-dry gauze dressings (Choice D) involve placing moist saline gauze onto a wound bed and allowing it to dry before removal. This method is used for mechanical debridement of wounds with necrotic tissue, and it's not suitable for a stage I pressure ulcer. In fact, using wet-to-dry dressings on a superficial wound could cause trauma and hinder healing.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

(Correct Choice) Checking pupillary response to light is a critical first step in the assessment of a client with multiple injuries following a motor vehicle crash. Pupillary changes can indicate neurological issues, increased intracranial pressure, or damage to the brainstem. Rapidly assessing pupil size, equality, and reactivity helps identify potential life-threatening conditions.

Choice B rationale:

Checking the client's response to questions about place and time is important but not the highest priority in this scenario. Neurological and physiological stability should be addressed first to ensure the client's overall well-being.

Choice C rationale:

Assessing capillary refill is valuable in assessing peripheral circulation and hydration status. However, it is not the primary concern when dealing with a client who has potentially sustained traumatic injuries, where neurological and intracranial issues need to be ruled out or addressed urgently.

Choice D rationale:

Evaluating chest expansion is relevant for assessing lung function and detecting potential injuries like rib fractures. However, given the context of a trauma client, focusing on neurological assessment takes precedence over respiratory assessment in the immediate term.

A. Ask the surgeon to discuss the procedure with the client. B. Explain the procedure in detail to the client. C. Encourage the client to reread the consent form before signing. D. Tell the client that the surgeon will explain it to him in the operating room.

Correct Answer is A

Explanation

Choice A rationale:

It's essential to ensure that the client fully understands the surgical procedure and its implications before signing the informed consent form. If the client expresses confusion or lack of understanding, the nurse should involve the surgeon to address the concerns directly. The surgeon is the most appropriate person to provide comprehensive information about the procedure, potential risks, benefits, and alternatives. This promotes patient autonomy and informed decision-making, aligning with ethical principles.

Choice B rationale:

While educating the client about the procedure is important, it's not the nurse's role to provide detailed explanations of surgical procedures. Additionally, the surgeon possesses the necessary expertise to explain medical procedures accurately. Relying on the surgeon for this explanation maintains professional boundaries and ensures accurate information dissemination.

Choice C rationale:

Encouraging the client to reread the consent form is insufficient if the client did not initially understand the explanation. The consent form might contain complex medical language, and the client might need direct communication with the surgeon to address specific concerns. Merely re-reading the form might not alleviate the client's confusion.

Choice D rationale:

Telling the client that the surgeon will explain the procedure in the operating room is inappropriate. The client's concerns should be addressed promptly, and the explanation should occur before the surgery, allowing the client to make an informed decision. Operating rooms are not the appropriate setting for obtaining informed consent.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse in the trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Correct Answer is A

Explanation

A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that surgeon said." Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

A nurse is interviewing a female client who is Hispanic. The client's husband answers the questions and states, "She speaks only a little English." Which of the following actions should the nurse take?

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

A nurse in the Medical-Surgical unit is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?