A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Alginate dressing

Hydrogel dressing

Transparent dressing

Wet-to-dry gauze dressing

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Alginate dressings are typically used for wounds with moderate to heavy exudate because they are highly absorbent. Stage I pressure ulcers do not usually produce exudate, making alginate dressings unnecessary and inappropriate for this type of wound.

Choice B Reason:

Hydrogel dressings are designed to provide moisture to dry wounds and are more suitable for wounds with minimal to no exudate. While they can be used for stage I pressure ulcers, they are not the most common choice as these ulcers do not typically require additional moisture.

Choice C Reason:

Transparent dressings are ideal for stage I pressure ulcers because they protect the skin from friction and shear while allowing for continuous observation of the wound. These dressings maintain a moist environment, which is beneficial for healing, and are easy to apply and remove without causing additional trauma to the skin.

Choice D Reason:

Wet-to-dry gauze dressings are generally used for debridement of necrotic tissue in more advanced wounds. They are not suitable for stage I pressure ulcers, which do not have necrotic tissue and do not require debridement.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason:

Sclera is correct. The sclera, or the white part of the eye, is a reliable site to assess for jaundice, especially in dark-skinned individuals. Jaundice causes a yellowish discoloration of the sclera due to the accumulation of bilirubin in the blood. This yellowing is often more noticeable in the sclera than in other parts of the body.

Choice B Reason:

Dorsal surface of the foot is incorrect. The dorsal surface of the foot is not a reliable site for assessing jaundice, particularly in dark-skinned individuals. The skin on the feet may not show the yellow discoloration as clearly as the sclera.

Choice C Reason:

Pinnae of the ears is incorrect. The pinnae, or outer parts of the ears, are not typically used to assess for jaundice. The skin in this area may not show the yellow discoloration as effectively as the sclera.

Choice D Reason:

Palmar surface of the hand is incorrect. While the palms can sometimes show signs of jaundice, they are not as reliable as the sclera. The yellow discoloration may be less noticeable on the palms, especially in dark-skinned individuals.

A. Hold the cane on the right side to provide support for the weaker leg. B. Advance the right leg and the cane together to support the weaker leg. C. Remove the rubber tip when using the cane. D. Place the cane approximately 61 cm (24 inches) in front of her foot before advancing.

Correct Answer is A

Explanation

Choice A reason: Holding the cane on the opposite side of the weaker leg is the correct technique. For a client with left-sided weakness, holding the cane on the right side provides better support and balance. This method helps distribute weight away from the weaker side and reduces the risk of falls. The cane should be moved simultaneously with the weaker leg to maintain stability.

Choice B reason: Advancing the right leg and the cane together is incorrect. The correct technique involves moving the cane and the weaker leg (left leg in this case) together. This coordination helps in maintaining balance and provides the necessary support to the weaker side. Moving the stronger leg and the cane together does not offer the same level of support.

Choice C reason: Removing the rubber tip when using the cane is not advisable. The rubber tip provides traction and prevents the cane from slipping on various surfaces. Removing it would increase the risk of falls and injuries. The rubber tip is an essential safety feature of the cane.

Choice D reason: Placing the cane approximately 61 cm (24 inches) in front of the foot is too far. The cane should be placed about 15-20 cm (6-8 inches) in front of the foot to ensure stability and ease of movement. Placing the cane too far ahead can cause instability and make walking more difficult.

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A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Nursing Test Bank

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