A nurse is planning care for a client who has an infected wound with significant exudate.

The nurse should plan to use which of the following dressings to cover the wound?

Polymeric membrane dressing

Hydrofiber dressing

Hydrogel dressing

Hydrocolloid dressing

Answer and Explanation

The Correct Answer is B

Choice A rationale: this is a type of non-adherent dressing that can be used for wounds with minimal exudates hence this is not suitable for wounds with significant exudate since it causes maceration and leakage.
Choice B rationale: this is an absorbent dressing that can be used in wounds with moderate-significant exudate since it moistens the wound environment while facilitating autolytic debridement by forming a gel in contact with the exudate.
Choice C rationale: this is a type of hydrating dressing containing water or glycerin-based gel that is suitable for use in wounds with minimal exudate.
Choice D rationale: this is a type of occlusive dressing suitable for wounds with minimal-moderate exudates. It is unsuitable for wounds with significant exudate since it can result in maceration and leakage.

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Correct Answer is C

Explanation

Choice A rationale: tachycardia is an expected finding in burns patients due to the increase in metabolic rate and fluid loss.
Choice B rationale: a urine output of 25 ml/hr is too low for an individual with burns hence the need for adequate fluid resuscitation. However, this is not a priority sign compared with the difficulty in breathing.
Choice C rationale: difficulty in swallowing is an indicator of airway edema which may compromise the patients breathing and oxygenation which may result in death. Therefore, the healthcare provider should be notified to assess the need for intubation.
Choice D rationale: Pain of 6 on a scale of 0 to 10 is moderate and is expected due to burns and can be managed with analgesics and nonpharmacological interventions.

A. Question the charge nurse about care deficits that might have contributed to the ulcer's development. B. Document what the nurse believes was the cause of ulcer development C. Include any relevant statements the client made about the ulcer D. Document in the client's medical record that she completed an incident report

Correct Answer is C

Explanation

Choice A rationale: The nurse should not include any opinions, judgments, or blame in the incident report, as this could be used as evidence in a legal case. Therefore, the nurse should not question the charge nurse about care deficits.
Choice B rationale: The nurse should not include any opinions, judgments, or blame in the incident report, as this could be used as evidence in a legal case. Therefore, the nurse should not document what the nurse believes was the cause of ulcer development.
Choice C rationale: This is important because it provides factual information about the client's condition and perception of the event, which could help in identifying the factors that contributed to the ulcer development and preventing further complications.
Choice D rationale: Documenting in the client's medical record that the nurse completed an incident report is not the primary purpose of the incident report itself. Incident reports are internal documents used by the healthcare facility to track and investigate events. The documentation in the client's medical record should focus on the client's clinical condition, care provided, and response to treatment.

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A nurse is planning care for a client who has an infected wound with significant exudate. The nurse should plan to use which of the following dressings to cover the wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority report to the provider?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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A nurse is planning care for a client who has an infected wound with significant exudate.

The nurse should plan to use which of the following dressings to cover the wound?