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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Applying petroleum jelly to the nares is not necessary in this situation. Oxygen therapy through a nasal cannula aims to deliver oxygen to the client's respiratory system. Applying petroleum jelly might interfere with the oxygen delivery and is not a standard practice.
Choice B rationale:
Removing the nasal cannula while the client eats reduces the oxygen supply during a time when the body's oxygen demand might increase due to the digestive process. It's important to maintain consistent oxygen therapy, even during meals.
Choice C rationale:
Attaching a humidifier bottle to the base of the flow meter is not necessary for oxygen therapy at 5 L/min via nasal cannula. Humidification is usually needed at higher oxygen flow rates to prevent drying of the mucous membranes.
Choice D rationale:
Securing the oxygen tubing to the bed sheet near the client's head is the correct action. This ensures that the tubing is not pulled or tugged during movement, maintaining a steady flow of oxygen. Placing it near the client's head prevents kinking or tangling of the tubing and allows the client to move without disrupting the therapy.
Correct Answer is C
Explanation
Choice A rationale:
Decreased tactile fremitus refers to a decreased vibration felt upon palpation of the chest, which might be indicative of conditions such as pleural effusion or pneumothorax. It is not directly associated with a crackling sensation.
Choice B rationale:
Pleural friction fremitus occurs when inflamed pleural surfaces rub against each other during breathing. It typically results in a grating sensation rather than a crackling sensation. It is associated with conditions like pleuritis.
Choice C rationale:
(Correct Choice) Crepitus refers to a crackling or grating sound/sensation that occurs when gas or air accumulates in the subcutaneous tissue. It can indicate a serious condition, such as subcutaneous emphysema, which might result from lung or chest wall injury, infections, or surgery.
Choice D rationale:
Rhonchal fremitus is associated with coarse breath sounds caused by thick secretions in the larger airways. It is felt as vibration during palpation and is not related to crackling sensations.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.