The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

Debride the wound.

Manage drainage from the wound.

Document the wound.

Monitor the wound.

Answer and Explanation

The Correct Answer is A

A: Debriding the wound is the next step for a black (necrotic) pressure ulcer. Removing the dead tissue is essential to promote healing and prevent infection.

B: Managing drainage is important for wound care but is not the immediate next step for a necrotic ulcer.

C: Documenting the wound is necessary but does not address the need for debridement.

D: Monitoring the wound is important, but active intervention (debridement) is required for a necrotic ulcer to promote healing.

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Correct Answer is D

Explanation

A: Proceeding to measure the oral temperature immediately after the client has eaten ice chips is not appropriate. The cold temperature can affect the accuracy of the reading.

B: Documenting that the nurse was unable to measure the client’s temperature is unnecessary. The nurse can take steps to ensure an accurate measurement by waiting.

C: Providing the client a sip of warm water and waiting 5 minutes is not sufficient to counteract the effect of the ice chips on the oral temperature reading.

D: Waiting 30 minutes before measuring the oral temperature is the correct action. This allows time for the oral cavity to return to its normal temperature, ensuring an accurate reading.

A. Expect some swelling in the hands and feet. B. Take the medication at bedtime. C. Eat foods that contain plenty of potassium. D. Take aspirin if headaches develop.

Correct Answer is C

Explanation

A: Expecting some swelling in the hands and feet is incorrect. Furosemide is a diuretic used to reduce fluid buildup, so swelling should decrease, not increase.
B: Taking the medication at bedtime is not recommended because furosemide increases urine output, which can disrupt sleep. It is better to take it in the morning.
C: Eating foods that contain plenty of potassium is important because furosemide can cause potassium loss. Consuming potassium-rich foods helps maintain electrolyte balance and prevent hypokalemia.
D: Taking aspirin if headaches develop is not related to the use of furosemide. The nurse should address headache management separately and ensure the client understands the specific instructions for furosemide use.

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The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is measuring a client’s oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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