A nurse is caring for a patient with a stage 3 pressure ulcer. What nursing intervention should the nurse prioritize based on the information provided in the text?
"I'll administer antibiotics to prevent infection.".
"I'll assess the patient's pain level and provide appropriate pain management.".
"I'll educate the patient on the importance of mobility exercises.".
"I'll optimize the patient's nutrition and hydration.".
The Correct Answer is D
Choice A rationale:
Administering antibiotics to prevent infection is not the primary nursing intervention for a stage 3 pressure ulcer.
While infection prevention is important, optimizing nutrition and hydration (Choice D) takes precedence in this case.
Proper nutrition and hydration are essential for tissue healing and preventing further deterioration of the wound.
Infection prevention measures like antibiotics may be considered if there are signs of infection, but they are not the first-line intervention.
Choice B rationale:
Assessing the patient's pain level and providing appropriate pain management (Choice B) is an important aspect of care for a patient with a stage 3 pressure ulcer, but it is not the highest priority.
Pain management should be addressed, but it should not take precedence over optimizing nutrition and hydration (Choice D), which is crucial for wound healing.
Choice C rationale:
Educating the patient on the importance of mobility exercises (Choice C) is an essential aspect of preventing pressure ulcers, but for a patient with an existing stage 3 pressure ulcer, the priority should be on wound management and nutrition.
While mobility exercises are beneficial, they should not be prioritized over optimizing nutrition and hydration (Choice D) to support the healing process.
Choice D rationale:
Optimizing the patient's nutrition and hydration (Choice D) is the most appropriate nursing intervention for a patient with a stage 3 pressure ulcer.
Proper nutrition and hydration are essential for tissue repair and wound healing.
Inadequate nutrition can delay healing and increase the risk of complications, making this the highest priority intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
"Advanced age is the primary risk factor for pressure ulcers in individuals with diabetes." While advanced age is a risk factor for pressure ulcers, it is not the primary risk factor in individuals with diabetes.
Diabetes itself presents several risk factors, including compromised blood flow and oxygenation, which increase the susceptibility to pressure ulcers.
Choice B rationale:
"Sensory deficits in diabetes make patients more resistant to pressure ulcers." This statement is incorrect.
Sensory deficits in diabetes, such as neuropathy, make patients more vulnerable to pressure ulcers.
These deficits can lead to reduced awareness of discomfort or pain, allowing pressure to be applied to areas without the patient's awareness.
Choice C rationale:
"Poor nutrition and hydration do not contribute to the development of pressure ulcers in diabetic patients." This statement is not accurate.
Poor nutrition and hydration can significantly contribute to the development of pressure ulcers in diabetic patients.
Adequate nutrition and hydration are essential for maintaining skin integrity and supporting the healing process.
Choice D rationale:
"Individuals with diabetes are more prone to pressure ulcers due to compromised blood flow and oxygenation." This statement is correct.
Diabetes can lead to compromised blood flow (peripheral vascular disease) and oxygenation (due to vascular damage), making individuals with diabetes more prone to pressure ulcers.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
The wound's warmth to the touch is not a primary factor to consider when selecting a dressing for a pressure ulcer.
The choice of dressing should primarily be based on the wound's characteristics, such as its depth, exudate level, and tissue involvement.
Choice B rationale:
The presence of a foul odor from the wound is an important factor to consider when selecting a dressing.
Malodorous wounds may indicate infection or necrotic tissue, and appropriate wound dressings can help manage odor and promote healing.
Choice C rationale:
The extent of tissue damage, including muscle and bone involvement, is a critical factor in choosing an appropriate dressing for a pressure ulcer.
Dressings should be selected based on the depth of the wound and the extent of tissue damage to support healing and prevent complications.
Choice D rationale:
The patient's mobility and pressure on vulnerable areas are essential considerations when selecting a dressing.
Dressings should help offload pressure from vulnerable areas and promote mobility while providing optimal wound care.
The choice of dressing should support the overall management of the patient's condition.
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