A nurse is caring for a client who is malnourished with poor skin integrity. The nurse should utilize which type of dressing to protect the client's bony prominences?

Foam

Non-adherent

Ace bandage

Hydrocolloid

Answer and Explanation

The Correct Answer is B

A. Foam:
Explanation: Foam dressings are highly absorbent and provide cushioning and protection to wounds. They are suitable for wounds with moderate to heavy drainage. While foam dressings are excellent for wound exudate management, they are not specifically designed for protecting bony prominences or areas with poor skin integrity.

B. Non-adherent:
Explanation: Non-adherent dressings are made from materials that do not stick to the wound bed. They are ideal for fragile skin, bony prominences, or superficial wounds where minimizing trauma during dressing changes is important. Non-adherent dressings are often used for preventing further skin damage in malnourished clients with poor skin integrity.

C. Ace bandage:
Explanation: Ace bandages, or elastic bandages, are primarily used for providing compression and support to injured joints or muscles. They are not designed for protecting bony prominences or fragile skin areas. Using an Ace bandage on a bony prominence could lead to pressure points and skin damage.

D. Hydrocolloid:
Explanation: Hydrocolloid dressings are absorbent and form a gel-like barrier when they come into contact with wound exudate. They provide a moist environment that supports healing and autolytic debridement. Hydrocolloid dressings are suitable for wounds with light to moderate drainage. While they are beneficial for certain wounds, they are not specifically indicated for protecting bony prominences in malnourished clients.

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 C

Explanation

A. Increased thickness of the subcutaneous skin layer - Aging typically results in thinning of the skin and subcutaneous tissue, making older adults more vulnerable to pressure ulcers rather than having increased thickness.

B. Changes in the character and quantity of bacterial skin flora - This is a common age-related change; however, it is not directly related to the course of treatment for a sacral pressure ulcer. Proper wound care can mitigate the impact of changes in skin flora.

C. Increased time required for wound healing - Aging often leads to a decline in the body's ability to repair and regenerate tissues, which can prolong the healing process of wounds, including pressure ulcers. Older adults may experience delayed wound healing compared to younger individuals.

D. Increased elasticity of the skin - Skin elasticity decreases with age, making older adults more susceptible to skin breakdown and pressure ulcers due to reduced skin resilience and ability to redistribute pressure. Increased elasticity would not affect the course of treatment positively but rather negatively in this context.

A. Promptly inform the primary provider. B. Reassess the client's neurovascular status in 15 minutes. C. Warm the client's foot and determine whether circulation improves. D. Reposition the client with the affected foot dependent.

Correct Answer is A

Explanation

Explanation:
A. Promptly inform the primary provider:
Explanation: Compartment syndrome is a medical emergency that requires immediate intervention. If a nurse suspects compartment syndrome due to symptoms like severe unrelieved pain, absent pulses, and pale extremities, the most appropriate action is to promptly inform the primary healthcare provider. The provider can assess the situation, order necessary diagnostic tests, and potentially arrange for emergent interventions like fasciotomy to relieve compartment pressure.

B. Reassess the client's neurovascular status in 15 minutes:
Explanation: Waiting for 15 minutes to reassess the client's neurovascular status is not appropriate in this situation. Compartment syndrome can progress rapidly, leading to irreversible tissue damage within a short time frame. Delaying assessment and intervention can result in significant complications.

C. Warm the client's foot and determine whether circulation improves:
Explanation: Warming the foot is not appropriate in this context. Compartment syndrome is caused by increased pressure within the muscle compartment, leading to compromised circulation. Warming the foot will not address the underlying issue of elevated compartment pressure and can potentially worsen the condition by dilating blood vessels and increasing pressure further.

D. Reposition the client with the affected foot dependent:
Explanation: Repositioning the client with the affected foot dependent is contraindicated in compartment syndrome. Elevating the limb can worsen the condition by further restricting blood flow. The limb should be kept at or slightly below the level of the heart to maintain adequate perfusion until medical intervention can be initiated.

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 is malnourished with poor skin integrity. The nurse should utilize which type of dressing to protect the client's bony prominences?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An 82-year-old diabetic client is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the client's course of treatment?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching?

A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first?

A nurse is talking with a young adult client who has a family history of osteoporosis, Which health promotion activity should the nurse recommend as a possible preventive measure?

A nurse is teaching a lactose intolerant client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. Which of the following foods should the nurse advise the client to increase in her diet?

A nurse is caring for a client who has a pulmonary embolism and has a new prescription for enoxaparin 1.5-2.5mg/kg subcutaneous. The client weighs 245 lbs. How many mg should the nurse administer for the low range of the dosage range? (Round the answer to the nearest whole number.)

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 female client has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this client?

An emergency department client is diagnosed with a hip dislocation. The client's family is relieved that the client has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurse's statement?