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 D

Explanation

A: Encouraging the client to consume a high-protein diet is beneficial for overall health and recovery but does not directly prevent the transmission of infection.

B: Changing the client’s bed linens each day is good practice for maintaining cleanliness but is not the most critical strategy for preventing infection transmission.

C: Placing the client in a room with positive-pressure airflow is used for protecting immunocompromised patients from outside infections, not for preventing the spread of infection from the client.

D: Performing hand hygiene before, during, and after direct contact with the client is the most effective strategy for preventing the transmission of infection. Proper hand hygiene is crucial in breaking the chain of infection and protecting both the client and healthcare providers.

A. Assess characteristics of her sputum. B. Assess pulse and respirations. C. Instruct to slowly exhale with pursed lips. D. Auscultate lung fields.

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.

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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?

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Naxlex Comprehensive Predictor Exams

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