A nurse is developing a plan of care for a client who has a stage pressure ulcer. Which of the following interventions should the nurse include in the plan?
Reposition the client at least every 2 hours.
Clean the wound with hydrogen peroxide solution.
Massage reddened areas with dressing changes.
Apply a heat lamp twice a day.
The Correct Answer is A
A: Repositioning the client at least every 2 hours is crucial for preventing further pressure ulcers and promoting healing. Regular repositioning helps to relieve pressure on vulnerable areas, improve circulation, and prevent skin breakdown.
B: Cleaning the wound with hydrogen peroxide solution is not recommended. Hydrogen peroxide can damage healthy tissue and delay wound healing. Saline or a gentle wound cleanser should be used instead.
C: Massaging reddened areas with dressing changes is not advisable. Massaging can cause further damage to already compromised skin and tissues. Gentle handling and avoiding pressure on these areas are more appropriate.
D: Applying a heat lamp twice a day is not a standard intervention for pressure ulcers. Heat lamps can cause burns and further damage to the skin. Maintaining a moist wound environment and using appropriate dressings are better practices.
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Related Questions
Correct Answer is D
Explanation
A: Assessing the characteristics of the sputum is important for understanding the nature of the infection and the effectiveness of the treatment, but it is not the first action to take before the procedure.
B: Assessing pulse and respirations is the first action the nurse should take. This provides baseline data on the client’s respiratory and cardiovascular status, which is crucial for monitoring the client’s response to the procedure and ensuring safety.
C: Instructing the client to slowly exhale with pursed lips is a technique used to improve breathing efficiency and oxygenation, but it is not the first action to take before the procedure.
D: Auscultating lung fields is important for assessing the client’s respiratory status and identifying areas of congestion or decreased breath sounds, but it should follow the initial assessment of pulse and respirations.
Correct Answer is C
Explanation
A: Checking the client’s skin every 8 hours is not frequent enough to prevent skin breakdown in a client with urinary incontinence. More frequent checks are necessary to identify and address any issues promptly.
B: Cleaning the client’s skin and perineum with hot water can cause skin irritation and dryness. It is better to use lukewarm water and gentle cleansers to maintain skin integrity.
C: Applying a moisture barrier ointment to the client’s skin is an effective way to prevent skin breakdown. The ointment creates a protective barrier that helps keep moisture away from the skin, reducing the risk of irritation and breakdown.
D: Requesting a prescription for the insertion of an indwelling urinary catheter is not the best first-line intervention for preventing skin breakdown. Catheters carry a risk of infection and should be used only when absolutely necessary.
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