The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Leave the dressing off until consulting with the healthcare provider.

Replace the gauze with a transparent dressing.

Increase the frequency of the dressing changes.

Apply a hydrocolloid gel dressing.

Answer and Explanation

The Correct Answer is D

Choice A reason: Leaving the dressing off is not advisable as it can expose the wound to potential infection and delay healing.

Choice B reason: A transparent dressing may not be the best choice for a stage 3 pressure injury with significant granulation tissue.

Choice C reason: Increasing the frequency of dressing changes without specific orders may not be necessary and could disrupt the healing process.

Choice D reason: A hydrocolloid gel dressing is appropriate for a stage 3 pressure injury as it maintains a moist environment, which is conducive to wound healing and granulation.

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Correct Answer is D

Explanation

The correct answer is choiced. Proceed with teaching the client how to walk with the crutches.

Choice A rationale:

Confer with the physical therapist for correct crutch size. This is unnecessary because the crutches are already correctly fitted.A space of three finger widths between the top of the crutch and the client’s axilla is appropriate to prevent pressure on the axilla and potential nerve damage.

Choice B rationale:

Ask the client to sit down while the crutch length is adjusted. This action is not needed since the crutches are already properly adjusted.Adjusting the crutch length further could lead to improper fitting, which might cause discomfort or injury.

Choice C rationale:

Assess the client for signs of diminished circulation in the hands. While assessing circulation is important, it is not directly related to the fitting of the crutches.Proper crutch fitting focuses on ensuring there is no pressure on the axilla and that the client can use the crutches comfortably.

Choice D rationale:

Proceed with teaching the client how to walk with the crutches. This is the correct action because the crutches are already properly fitted.The nurse should now focus on educating the client on the correct use of the crutches to ensure safe and effective mobility.

A. C-reactive protein level B. Serum potassium and sodium levels C. Neutrophil count D. Platelet count

Correct Answer is A

Explanation

Choice A reason: An increased boundary of the wound suggests possible infection or inflammation. C-reactive protein (CRP) is an acute-phase reactant produced by the liver in response to inflammation. A CRP test can help assess the severity of inflammation or infection. The normal range for CRP is generally below 10 mg/L.

Choice B reason: While serum potassium and sodium levels are important electrolytes to monitor, they are not directly related to wound assessment or infection. Normal ranges for potassium are 3.6 to 5.2 mmol/L, and for sodium, 135 to 145 mEq/L.

Choice C reason: Neutrophils are white blood cells that respond to infection. While an elevated neutrophil count can indicate infection, it is not as specific as CRP for inflammation. The normal range for neutrophils is 2,500 to 6,000 cells/mcL.

Choice D reason: Platelets are involved in clotting and would not necessarily change due to wound infection or inflammation. The normal platelet count range is 150,000 to 450,000 platelets/mcL.

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The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Correct Answer is D

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Correct Answer is A

Explanation

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