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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Chewing sublingual medication is incorrect. Sublingual medications are designed to dissolve under the tongue for rapid absorption into the bloodstream.
B: Letting the medication dissolve completely is correct. This ensures that the medication is absorbed properly and works effectively.
C: There is no restriction on drinking juice with sublingual medication unless specified by the healthcare provider. This statement does not indicate a clear understanding of sublingual administration.
D: Placing the medication between the cheek and gum is incorrect for sublingual medications. This method is used for buccal medications, not sublingual ones.
Correct Answer is D
Explanation
A: Proceeding to measure the oral temperature immediately after the client has eaten ice chips is not appropriate. The cold temperature can affect the accuracy of the reading.
B: Documenting that the nurse was unable to measure the client’s temperature is unnecessary. The nurse can take steps to ensure an accurate measurement by waiting.
C: Providing the client a sip of warm water and waiting 5 minutes is not sufficient to counteract the effect of the ice chips on the oral temperature reading.
D: Waiting 30 minutes before measuring the oral temperature is the correct action. This allows time for the oral cavity to return to its normal temperature, ensuring an accurate reading.
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