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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is C
Explanation
A: Hypertension is not typically a late sign of hypoxemia. It can occur in various conditions but is not specific to hypoxemia.
B: Tachycardia is an early sign of hypoxemia as the body attempts to compensate for low oxygen levels by increasing the heart rate.
C: Pallor is a late sign of hypoxemia. It indicates poor oxygenation and perfusion, often seen when the body can no longer compensate for the lack of oxygen.
D: Bradypnea, or slow breathing, is not a typical sign of hypoxemia. Hypoxemia usually causes an increase in respiratory rate (tachypnea) as the body tries to take in more oxygen.
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