A nurse is performing wound care for an older adult patient who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?

Antimicrobial.

Wet-to-dry.

Transparent.

Dry, sterile.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Antimicrobial dressings are typically used for wounds that are infected or at high risk of infection. A stage I pressure ulcer, which involves intact skin with non-blanchable redness, would not typically require an antimicrobial dressing.
Choice B rationale
Wet-to-dry dressings are used for mechanical debridement of wounds with necrotic tissue. A stage I pressure ulcer does not involve necrotic tissue, so this type of dressing would not be appropriate.
Choice C rationale
Transparent dressings are often used for stage I pressure ulcers. They provide a protective layer over the wound, promoting a moist environment and facilitating the healing process.
Choice D rationale

Dry, sterile dressings are typically used for wounds that need to be kept dry. A stage I pressure ulcer benefits from a moist healing environment, which can be provided by a transparent dressing.

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Correct Answer is D

Explanation

Choice A rationale
Pursed-lip breathing can help improve oxygenation and reduce shortness of breath in clients with COPD. However, it is not the priority action when a client reports difficulty breathing.
Choice B rationale
Increasing the oxygen flow rate without a physician’s order can lead to oxygen toxicity or suppress the respiratory drive in clients with COPD. Therefore, this is not the priority action.
Choice C rationale
Coughing and expectorating secretions can help clear the airways, but it is not the priority action when a client reports difficulty breathing.

Choice D rationale
Evaluating the client’s respiratory status is the priority action. The nurse should assess the client’s breath sounds, respiratory rate, use of accessory muscles, and oxygen saturation to determine the severity of the client’s difficulty breathing and guide further interventions.

A. 28% B. 70% C. 509% D. 36% .

Correct Answer is A

Explanation

The correct answer is Choice A. The client is receiving an oxygen concentration of 28%. Nasal cannulas can deliver oxygen at a flow rate ranging from 1 to 6 liters per minute (L/min), with

each additional liter increasing the fraction of inspired oxygen (FiO2) by 4%. Therefore, at 2 L/min, the client is receiving an oxygen concentration of 28%78.

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A nurse is performing wound care for an older adult patient who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing.What is the nurse’s priority action?

Correct Answer is D

Explanation

A client is receiving oxygen at 2 L/min via a nasal cannula. What oxygen concentration is the client receiving?

Correct Answer is A

Explanation

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