A nurse is planning care for a client who is comatose and has a stage II decubitus ulcer on the coccyx. Which of the following interventions is appropriate to include in the plan of care?

Massage the area to improve circulation

Provide the client with an alternating pressure mattress

Apply a sterile, dry gauze dressing over the client's wound

Place a donut-shaped cushion under the client when in a chair

Answer and Explanation

The Correct Answer is B

Choice A reason: Massaging the area of a pressure ulcer is contraindicated. Massage can damage fragile capillaries and tissues, worsening the ulcer and increasing the risk of further breakdown. It may also cause pain and inflammation. Therefore, this intervention is inappropriate for a stage II ulcer.

Choice B reason: An alternating pressure mattress is an evidence-based intervention that helps redistribute pressure across the body and reduces the risk of further skin breakdown. For a comatose client who cannot reposition themselves, this intervention is especially important. It promotes circulation and prevents worsening of the ulcer, making it the most appropriate choice.

Choice C reason: A sterile, dry gauze dressing is not the recommended treatment for a stage II ulcer. Stage II ulcers involve partial-thickness skin loss and require a moist wound environment to promote healing. Dry gauze can adhere to the wound bed, cause trauma during removal, and delay healing. Moist dressings such as hydrocolloids or foam dressings are preferred.

Choice D reason: Donut-shaped cushions are not recommended because they concentrate pressure around the wound edges, worsening ischemia and tissue damage. They can increase the risk of ulcer progression rather than prevent it. This intervention is inappropriate for pressure ulcer management.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Applying a saturated abdominal dressing (with sterile normal saline) is correct. Moist dressings prevent the exposed abdominal organs from drying out and reduce the risk of tissue necrosis. This is the immediate priority intervention until surgical repair can be performed.

Choice B reason: Cleansing the site with hydrogen peroxide is inappropriate because it can damage exposed tissues and increase the risk of infection. Hydrogen peroxide is not used for internal organ exposure.

Choice C reason: Covering the site with dry, sterile gauze is incorrect because dry gauze can adhere to the viscera, causing tissue damage when removed. Moist dressings are required to protect the organs.

Choice D reason: Reinserting protruding viscera is unsafe and contraindicated. Attempting to push organs back into the abdominal cavity can cause trauma, infection, and further complications. The nurse should protect the viscera and notify the surgical team immediately.

A. "I should choose foods that contain saturated fat instead of monounsaturated fat." B. "I should consume 30 grams of protein per day during my pregnancy." C. "I should avoid eating soft cheeses during my pregnancy." D. "I should limit my caffeine intake to 500 milligrams per day."

Correct Answer is C

Explanation

Choice A reason: Choosing foods with saturated fat instead of monounsaturated fat is incorrect. Saturated fats increase cardiovascular risk and should be limited. Monounsaturated fats, such as those found in olive oil and avocados, are healthier options during pregnancy.

Choice B reason: Consuming only 30 grams of protein per day is insufficient. Pregnant clients require about 71 grams of protein daily to support fetal growth, maternal tissue expansion, and increased blood volume.

Choice C reason: Avoiding soft cheeses is correct because they can harbor Listeria monocytogenes, which poses a risk of miscarriage, stillbirth, or neonatal infection. Pregnant clients should avoid unpasteurized dairy products to reduce infection risk.

Choice D reason: Limiting caffeine intake to 500 mg per day is too high. The recommended limit is about 200 mg per day to reduce risks of miscarriage, low birth weight, and preterm birth.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care for a client who is comatose and has a stage II decubitus ulcer on the coccyx. Which of the following interventions is appropriate to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1-day postoperative following abdominal surgery. On assessment, the nurse notices evisceration from the surgical site. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is providing nutritional teaching to a client who is at 10 weeks of gestation. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

Correct Answer is C

Explanation

A nurse is educating a client who has chemotherapy-induced peripheral neuropathy. Which of the following information should the nurse include in the teaching?

A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. Which of the following should the nurse include in the teaching?

A nurse is performing postmortem care on a client. Which of the following actions should the nurse take?

A nurse is caring for a client who has difficulty holding utensils while eating. The nurse should obtain a referral for which of the following members of the interprofessional team?

A nurse is reviewing the medical records of four clients. Which of the following prescriptions represents correct documentation?

A nurse in an urgent care clinic is caring for a client who sprained their ankle. Which of the following provider prescriptions should the nurse expect?

A nurse is caring for an infant who is postoperative following the placement of a ventriculoperitoneal shunt for treatment of hydrocephalus. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a new diagnosis of gout. Which of the following medications should the nurse anticipate the provider to prescribe?