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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increased urinary output: Phenazopyridine (Pyridium) does not directly impact urinary output. Its primary function is to provide relief from urinary pain, burning, and discomfort associated with urinary tract infections (UTIs) or other urinary conditions. It does not affect the amount of urine a person produces.
B. Decreased WBC's: Phenazopyridine does not directly influence white blood cell count (WBCs). WBC count is an indicator of the body's immune response and is typically used to assess the presence of infection. Phenazopyridine provides symptomatic relief but does not affect the underlying infection or the body's immune response to it.
C. Increased uric acid: Phenazopyridine does not affect uric acid levels. Uric acid is a waste product that is excreted by the kidneys. Elevated uric acid levels can be associated with conditions like gout, but Phenazopyridine does not have any direct impact on these levels.
D. Decreased bladder pain/spasms: Phenazopyridine is intended to relieve symptoms such as bladder pain, spasms, burning sensation, and discomfort experienced during urination. Therefore, the effectiveness of Phenazopyridine is indicated by a reduction in these symptoms. If the patient reports a decrease in bladder pain and spasms, it suggests that the medication is working to alleviate the discomfort associated with urinary tract issues.
Correct Answer is D
Explanation
A. McBurney's point on the abdomen: McBurney's point is a location in the right lower quadrant of the abdomen that is significant in the assessment for appendicitis. It is not relevant to the assessment of pyelonephritis, which is a kidney infection.
B. Psoas sign at the knee: The psoas sign is a test for appendicitis, not pyelonephritis. It involves the patient lying on their back and lifting their right leg against resistance. If this movement causes pain in the lower right abdomen, it could indicate irritation of the psoas muscle due to an inflamed appendix.
C. Rovsing's Sign on the abdomen: Rovsing's sign is also a test for appendicitis. It involves palpating the left lower quadrant of the abdomen and observing if it causes pain in the right lower quadrant. The presence of pain in the right lower quadrant during palpation of the left lower quadrant can indicate appendicitis. This sign is not specific to pyelonephritis.
D. Costovertebral angle (CVA) on the back: The CVA is located on the back at the angle formed by the 12th rib and the spine. Percussion of the CVA is a common technique used to assess for kidney tenderness. In the case of acute pyelonephritis, infection and inflammation of the kidneys can cause tenderness and pain in the CVA area. Therefore, this area is assessed for pain related to kidney infections like pyelonephritis.
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