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 A

Explanation

A: Aspirin is given as an antiplatelet aggregate to prevent blood clots in clients with a history of myocardial infarction. It inhibits platelet aggregation, reducing the risk of further cardiac events.

B: While aspirin has analgesic properties, this is not the primary reason for its use in clients with a history of myocardial infarction.

C: Aspirin also has antipyretic properties, but this is not the reason for its use in preventing cardiac events.

D: Aspirin’s anti-inflammatory properties are beneficial, but the primary reason for its use in myocardial infarction is its antiplatelet effect.

A. Hypertension B. Tachycardia C. Pallor D. Bradypnea

Correct Answer is C

Explanation

A: Hypertension is not typically a late sign of hypoxemia. It can occur in various conditions but is not specific to hypoxemia.

B: Tachycardia is an early sign of hypoxemia as the body attempts to compensate for low oxygen levels by increasing the heart rate.

C: Pallor is a late sign of hypoxemia. It indicates poor oxygenation and perfusion, often seen when the body can no longer compensate for the lack of oxygen.

D: Bradypnea, or slow breathing, is not a typical sign of hypoxemia. Hypoxemia usually causes an increase in respiratory rate (tachypnea) as the body tries to take in more oxygen.

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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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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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