The nurse is caring for a patient with a healing Stage II pressure ulcer. The wound is clean and granulating. Which health care provider’s order will the nurse question?

Consult a dietitian.

Apply a hydrogel dressing.

Clean the wound with hydrogen peroxide.

Use a low-air-loss therapy unit.

Answer and Explanation

The Correct Answer is C

The correct answer is C.

A: Consulting a dietitian is a beneficial order for a patient with a pressure ulcer. Proper nutrition, especially adequate protein intake, is crucial for wound healing. A dietitian can help ensure the patient receives the necessary nutrients to support tissue repair and recovery.

B: Applying a hydrogel dressing is appropriate for a clean, granulating Stage II pressure ulcer. Hydrogel dressings maintain a moist wound environment, which promotes healing and provides pain relief. They are suitable for wounds with minimal to moderate exudate.

C: Cleaning the wound with hydrogen peroxide is not recommended for a healing pressure ulcer. Hydrogen peroxide can damage healthy granulating tissue and delay the healing process. It is better to use saline or a wound cleanser that does not harm the new tissue.

D: Using a low-air-loss therapy unit is beneficial for patients with pressure ulcers. These units help reduce pressure on the skin, improve circulation, and prevent further skin breakdown. They are an effective part of pressure ulcer management.

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Correct Answer is C

Explanation

A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.

B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.

C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.

D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.

A. 165 mg/dL B. 35 mg/dL C. 10 mg/dL D. 31 mg/dL

Correct Answer is B

Explanation

A: A BUN level of 165 mg/dL is extremely high and suggests severe dehydration or possible renal failure. This level is far above the normal range and indicates a critical condition.

B: A BUN level of 35 mg/dL is elevated and consistent with dehydration. Dehydration causes the kidneys to reabsorb more water, leading to higher concentrations of urea in the blood.

C: A BUN level of 10 mg/dL is within the normal range and does not indicate dehydration. This level suggests normal kidney function and hydration status.

D: A BUN level of 31 mg/dL is elevated and suggests dehydration. While not as high as 165 mg/dL, it still indicates that the patient is dehydrated and requires intervention.

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