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 C

Explanation

A. Performing range of motion:
Explanation: Range of motion exercises are important for preventing joint stiffness and muscle atrophy, especially in clients with casts. However, this is not the first priority. Ensuring adequate circulation and perfusion is crucial before initiating any exercises or movements, as compromised circulation could lead to serious complications.

B. Managing pain:
Explanation: Pain management is important for the client's comfort, but it is not the first priority in this context. Assessing circulation and ensuring there are no signs of compromised perfusion takes precedence. Pain management can follow once circulation has been confirmed as adequate.

C. Checking capillary refill:
Explanation: Checking capillary refill is the first priority when assessing a client with a cast. Capillary refill assesses peripheral circulation by pressing on the nail bed and observing how quickly color returns. Delayed capillary refill could indicate compromised blood flow, which is a serious concern and requires immediate intervention.

D. Discussing cast care:
Explanation: Educating the client about cast care is important, but it is not the first priority. Ensuring proper circulation and ruling out any signs of impaired perfusion must be addressed before discussing cast care instructions.

A. Provide the client with antipyretic therapy. B. Administer antibiotics to the client. C. Teach relaxation breathing to reduce the client's pain. D. Increase the client's protein intake.

Correct Answer is B

Explanation

A. Provide the client with antipyretic therapy. - Antipyretic therapy can help reduce fever, but addressing the underlying infection with antibiotics is crucial.

B. Administer antibiotics to the client. -The priority intervention for a client with acute osteomyelitis is to administer antibiotics promptly. Osteomyelitis is a severe bacterial infection of the bone, which requires aggressive antibiotic therapy to eradicate the infection. Delaying antibiotic treatment can lead to further complications and the spread of the infection.

C. Teach relaxation breathing to reduce the client's pain. - Pain management is important, but in the case of acute osteomyelitis, the priority is to eliminate the infection through antibiotics.

D. Increase the client's protein intake. - Adequate nutrition, including protein, is important for overall healing and immune function, but it is not the priority when dealing with an acute infection that requires immediate antibiotic treatment.

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

Correct Answer is C

Explanation

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Correct Answer is B

Explanation

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