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.

Answer and Explanation

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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Correct Answer is C

Explanation

A: Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to the bed frame, not the side rail, to prevent injury.

B: Ensuring four fingers fit under the restraints is too loose. The correct fit is typically two fingers to ensure the restraint is secure but not too tight.

C: Securing the restraints using a quick-release tie is correct. This allows for quick removal in case of an emergency.

D: Anticipating removing the restraints every 4 hours is incorrect. Restraints should be checked and potentially removed more frequently, typically every 2 hours, to assess skin integrity and circulation.

A. Renal dysfunction B. Pancreatic impairment C. Increased gastric motility D. Increased blood volume

Correct Answer is A

Explanation

A: Renal dysfunction is common in older adults and can lead to decreased clearance of medications from the body, increasing the risk of toxicity. Monitoring for signs of toxicity is crucial in this population.

B: Pancreatic impairment can affect digestion and insulin production but is not the primary reason for monitoring medication toxicity in older adults.

C: Increased gastric motility is not typically associated with aging. In fact, decreased gastric motility is more common and can affect drug absorption.

D: Increased blood volume is not a common physiological change in older adults. Decreased renal function and changes in body composition are more relevant factors affecting medication metabolism and excretion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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