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 C

Explanation

Choice A reason: While bowel incontinence is a concern, it does not pose an immediate threat to the client's physiological stability like fluid volume deficit does.

Choice B reason: Impaired bed mobility is important to address for long-term rehabilitation, but it is not the most immediate threat to life.

Choice C reason: Fluid volume deficit, especially due to diarrhea, can lead to dehydration and is a life-threatening condition that requires immediate intervention.

Choice D reason: Caregiver role strain is a significant issue but does not take precedence over the client's immediate physical health needs.

A. Confirm that bowel sounds are present. B. Measure the client's total body weight. C. Evaluate the client's ability to swallow. D. Observe for signs of fluid volume deficit.

Correct Answer is A

Explanation

Choice A reason: Before initiating tube feeding, it is crucial to ensure that the gastrointestinal system is functioning. The presence of bowel sounds indicates peristalsis, which is necessary for the digestion and absorption of the feeding.

Choice B reason: While measuring the client's total body weight is important for overall assessment and monitoring of nutritional status, it is not the most critical assessment before starting tube feeding.

Choice C reason: Evaluating the client's ability to swallow is not relevant in this scenario since the client will be receiving nutrition through a feeding tube due to malnutrition and dehydration.

Choice D reason: Observing for signs of fluid volume deficit is important, but the immediate concern before starting tube feeding is to confirm gastrointestinal activity through the presence of bowel sounds.

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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

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Explanation

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Explanation

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