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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: Dyspnea, or difficulty breathing, can occur in various conditions but is not a primary manifestation of hypovolemia. Hypovolemia primarily affects the cardiovascular system due to reduced blood volume.
B: Increased blood pressure is not a typical manifestation of hypovolemia. In fact, hypovolemia usually leads to decreased blood pressure due to the reduced volume of circulating blood.
C: A weak pulse is a common manifestation of hypovolemia. The reduced blood volume leads to decreased cardiac output, resulting in a weak and thready pulse.
D: Decreased heart rate is not typical in hypovolemia. The body usually compensates for low blood volume by increasing the heart rate (tachycardia) to maintain adequate circulation.
Correct Answer is D
Explanation
A: Stopping an antibiotic once feeling better is incorrect. Antibiotics should be taken for the full prescribed course to ensure the infection is fully treated and to prevent antibiotic resistance.
B: Skipping a dose if 30 minutes late is not recommended. Most medications can be taken within a short window of the scheduled time. The patient should follow specific instructions provided by the healthcare provider.
C: Parenteral medications are administered via injection and do not need to be taken with food. This statement indicates a misunderstanding of the medication route.
D: Rotating the sites for a transdermal patch is correct. This practice helps prevent skin irritation and ensures consistent absorption of the medication.
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