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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
Step 1: Determine the total volume to be infused.
- Total volume = 50 mL
- Result: 50 mL
Step 2: Determine the total time for infusion in hours.
- Total time = 30 minutes
- Convert minutes to hours: 30 minutes ÷ 60 minutes/hour = 0.5 hours
- Result: 0.5 hours
Step 3: Calculate the flow rate in mL/hr.
- Flow rate (mL/hr) = Total volume (mL) ÷ Total time (hours)
- Flow rate (mL/hr) = 50 mL ÷ 0.5 hours
- Result: 50 ÷ 0.5 = 100
Final Answer: The nurse should set the IV pump to deliver 100 mL/hr.
Correct Answer is D
Explanation
Choice A reason:
Erythromycin is a macrolide antibiotic and is generally considered safe for patients with a penicillin allergy. It does not share the beta-lactam ring structure that is responsible for cross-reactivity in penicillin-allergic patients.
Choice B reason:
Gentamicin is an aminoglycoside antibiotic and is also safe for patients with a penicillin allergy. It does not have the beta-lactam ring structure and therefore does not pose a risk of cross-reactivity.
Choice C reason:
Amphotericin B is an antifungal medication and is not related to penicillin. It is safe for use in patients with a penicillin allergy as it does not share any structural similarities with penicillin.
Choice D reason:
Amoxicillin-clavulanate is a combination of a penicillin antibiotic (amoxicillin) and a beta-lactamase inhibitor (clavulanate). Since it contains amoxicillin, it should not be given to patients with a penicillin allergy due to the risk of an allergic reaction.
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