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.

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Correct Answer is ["200"]

Explanation

To calculate the rate at which the nurse should program the pump in milliliters per hour, you can use the following formula:

Rate (mL/hour) = Volume (mL) / Time (hours)

In this case, the volume is 1,000 mL (1 liter), and the time is 5 hours. Plugging these values into the formula:

Rate (mL/hour) = 1,000 mL / 5 hours = 200 mL/hour

So, the nurse should program the pump to administer the normal saline at a rate of 200 milliliters per hour.

A. The longer the joint is displaced, the more difficult it is to get it back in place. B. Avascular necrosis may develop at the site if it is not promptly resolved. C. The client's pain will increase until the joint is realigned. D. Dislocation can become permanent if the process of bone remodeling begins.

Correct Answer is A

Explanation

A. The longer the joint is displaced, the more difficult it is to get it back in place:
This statement is correct. Prompt reduction of a dislocated joint is important because the longer the joint remains out of place, the more difficult it becomes to realign it. Delayed reduction can lead to complications and makes the process more challenging for healthcare providers.

B. Avascular necrosis may develop at the site if it is not promptly resolved:
Avascular necrosis is a condition where bone tissue dies due to a lack of blood supply. While it is a potential complication of hip dislocation, it is not the immediate rationale for considering hip dislocation a medical emergency. The urgency primarily lies in the difficulty of reducing the dislocation and preventing further complications.

C. The client's pain will increase until the joint is realigned:
This statement is partially correct. While it is true that dislocated joints are extremely painful, the urgency in reducing the dislocation is not solely based on pain management. It is essential to prevent complications, restore joint function, and minimize long-term damage to the affected area.

D. Dislocation can become permanent if the process of bone remodeling begins:
This statement is accurate. If a dislocated joint is not promptly reduced, the surrounding tissues may undergo changes, and the process of bone remodeling can begin. This can lead to the dislocation becoming more difficult or even impossible to reduce, resulting in a permanent dislocation. Early intervention is essential to prevent this outcome.

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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

A nurse is to administer one 1L bag of normal saline to a client over 5 hours. At what rate should the nurse program the pump in milliliters per hour? (Round to the whole number. Assume no interruptions.)

Correct Answer is ["200"]

Explanation

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?

Correct Answer is A

Explanation

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