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.

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Correct Answer is D

Explanation

Choice A reason: Low-protein, low-potassium diet

A low-protein, low-potassium diet is not typically recommended for acute glomerulonephritis. While protein intake may need to be moderated to reduce the workload on the kidneys, potassium restriction is usually not necessary unless there is hyperkalemia (high potassium levels) present. The primary dietary focus should be on managing fluid and sodium intake to control edema and hypertension.

Choice B reason: Regular diet, no added salt

A regular diet with no added salt is a step in the right direction but may not be sufficient for managing acute glomerulonephritis with significant edema. Sodium restriction is crucial to help reduce fluid retention and control blood pressure. Therefore, a more stringent low-sodium diet is often necessary.

Choice C reason: Low-carbohydrate, low-protein diet

A low-carbohydrate, low-protein diet is not appropriate for managing acute glomerulonephritis. Carbohydrate intake does not directly impact kidney function in this context, and protein intake should be moderated rather than severely restricted. The focus should be on sodium and fluid management.

Choice D reason: Low-sodium, fluid-restricted diet

A low-sodium, fluid-restricted diet is the most appropriate choice for a client with acute glomerulonephritis and peripheral edema. Reducing sodium intake helps to minimize fluid retention and control blood pressure, while fluid restriction helps to prevent further edema and manage the workload on the kidneys. This dietary approach is essential for managing the symptoms and complications associated with acute glomerulonephritis.

A. Increased urinary output B. Hyperactive bowel sounds C. Bradycardia D. Nausea and vomiting

Correct Answer is D

Explanation

Choice A reason: Increased urinary output is not a typical manifestation of peritonitis. Peritonitis, especially in the context of peritoneal dialysis, does not usually affect urinary output directly. Instead, it primarily affects the peritoneal cavity and can lead to symptoms such as abdominal pain and tenderness.

Choice B reason: Hyperactive bowel sounds are not commonly associated with peritonitis. In fact, peritonitis can lead to decreased bowel sounds due to the inflammation and irritation of the peritoneum, which can cause paralytic ileus (a temporary cessation of bowel movements).

Choice C reason: Bradycardia (a slower than normal heart rate) is not a typical symptom of peritonitis. Peritonitis can cause systemic symptoms such as fever and tachycardia (an increased heart rate) due to the body’s inflammatory response to infection.

Choice D reason: Nausea and vomiting are common manifestations of peritonitis. The inflammation of the peritoneum can irritate the gastrointestinal tract, leading to these symptoms. Additionally, peritonitis can cause abdominal pain, tenderness, and distention, which are also associated with nausea and vomiting.

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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?

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