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 D
Explanation
A: Placing the client supine with knees bent can help reduce strain on the abdominal area but is not the immediate first action.
B: Raising the head of the client’s bed 15 to 20 degrees is not the priority action in this situation.
C: Assessing the client for manifestations of shock is important but should follow the immediate action of protecting the eviscerated wound.
D: Covering the area with a sterile dressing moistened with 0.9% sodium chloride irrigation is the correct first action. This helps protect the exposed organs and tissues from contamination and keeps them moist until surgical intervention can be performed.
Correct Answer is D
Explanation
A: An oxygen saturation range of 80-100% is incorrect. Saturation levels below 90% are considered low and may indicate hypoxemia, requiring medical attention.
B: An oxygen saturation range of 93-100% is generally acceptable, but the ideal range is slightly higher to ensure adequate oxygenation.
C: An oxygen saturation range of 90-100% includes levels that are borderline low. While 90% is often used as a threshold for concern, the optimal range is higher.
D: An oxygen saturation range of 95-100% is considered normal and indicates adequate oxygenation of the blood. This range ensures that tissues receive sufficient oxygen to function properly.
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