A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Apply a heat lamp twice a day.

Reposition the client at least every 2 hours.

Massage reddened areas with dressing changes.

Clean the wound with hydrogen peroxide solution.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Applying a heat lamp twice a day is not recommended for treating stage 3 pressure ulcers. Heat lamps can cause burns and further damage to the already compromised skin. The primary goal in treating pressure ulcers is to reduce pressure, keep the area clean, and promote healing. Heat lamps do not contribute to these goals and can potentially worsen the condition.

Choice B reason:

Repositioning the client at least every 2 hours is a crucial intervention for managing stage 3 pressure ulcers. Frequent repositioning helps to alleviate pressure on the affected area, improving blood flow and preventing further tissue damage. This practice is essential in preventing the progression of pressure ulcers and promoting healing. It is one of the most effective strategies in pressure ulcer management.

Choice C reason:

Massaging reddened areas with dressing changes is not advisable. Massaging can cause additional trauma to the skin and underlying tissues, potentially worsening the ulcer. Instead, gentle handling and appropriate wound care techniques should be used to avoid further damage. Massaging can also disrupt the healing process and increase the risk of infection.

Choice D reason:

Cleaning the wound with hydrogen peroxide solution is not recommended for stage 3 pressure ulcers. Hydrogen peroxide can damage healthy tissue and delay the healing process. It is better to use saline or other wound cleaning solutions that are gentle and effective in removing debris without harming the tissue. Proper wound cleaning is essential to prevent infection and promote healing.

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 A

Explanation

Choice A reason: 90 bpm is the threshold below which the nurse should withhold digoxin for a 6-month-old infant. Digoxin can slow the heart rate, and administering it when the heart rate is already low can increase the risk of bradycardia, a serious heart rhythm disturbance.

Choice B reason: 100 bpm is above the threshold for withholding digoxin in a 6-month-old infant. While it is important to monitor the heart rate, digoxin can be safely administered if the apical heart rate is above 90 bpm.

Choice C reason: 110 bpm is also above the threshold for withholding digoxin. This heart rate indicates that the infant’s heart rate is within a safe range for administering the medication.

Choice D reason: 120 bpm is well above the threshold for withholding digoxin. This heart rate is considered safe for administering the medication, as it indicates the heart rate is not too low.

A. Explain the discharge instructions to the client and parents. B. Perform a neurovascular assessment. C. Provide reassurance to the client and parents. D. Apply an ice pack to the casted leg.

Correct Answer is B

Explanation

Choice A reason:

Explaining the discharge instructions to the client and parents is important for ensuring they understand how to care for the cast and recognize signs of complications. However, this is not the immediate priority. The primary concern should be assessing the client’s current condition to ensure there are no immediate risks, such as compromised circulation or nerve damage.

Choice B reason:

Performing a neurovascular assessment is the priority action. This assessment involves checking for circulation, movement, and sensation in the affected limb. It is crucial to identify any signs of neurovascular compromise, such as decreased blood flow or nerve damage, which can occur with a new cast. Early detection of these issues can prevent serious complications.

Choice C reason:

Providing reassurance to the client and parents is important for their emotional well-being and can help reduce anxiety. However, it is not the immediate priority. Ensuring the physical health and safety of the client through a neurovascular assessment takes precedence.

Choice D reason:

Applying an ice pack to the casted leg can help reduce swelling and pain, but it is not the immediate priority. The first step should be to assess the neurovascular status to ensure there are no urgent issues that need to be addressed.

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 developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant’s apical heart rate is less than what rate?

Correct Answer is A

Explanation

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

Correct Answer is B

Explanation

A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?

A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members?

A nurse is caring for a client who has acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?

A nurse in an outpatient mental health clinic is treating a client who has bulimia nervosa. Exhibits A nurse is assessing the client during a follow-up visit. Select the 4 assessments that indicate a therapeutic response to the treatment plan.

A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include?

A nurse is caring for a client who has a seizure disorder. Exhibits A nurse is caring for a client who has a seizure disorder. What following actions should the nurse take? (Select all that apply.)

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client’s level of strength?