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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Even without mentioning the client's name, discussing health information in a public area like a breakroom can still lead to a HIPAA violation due to the possibility of revealing identifiable information indirectly.
Choice B reason: Discussing health history with a client behind a closed curtain maintains privacy and confidentiality, adhering to HIPAA regulations.
Choice C reason: Faxing health records to a client's primary healthcare provider is a common practice and is not a HIPAA violation if done securely and with proper consent.
Choice D reason: Sharing a client's discharge needs with other treatment team members is necessary for continuity of care and is not a HIPAA violation as long as it is done within the healthcare team.
Correct Answer is C
Explanation
Choice A reason: Fibromyalgia is a chronic condition characterized by widespread pain, but it is not directly associated with obstructive sleep apnea.
Choice B reason: Peptic ulcer disease is not commonly linked to obstructive sleep apnea.
Choice C reason: Hypertension is a known complication of obstructive sleep apnea due to the recurrent episodes of low oxygen levels during sleep, which can lead to increased blood pressure.
Choice D reason: Hypothyroidism is a condition affecting the thyroid gland and is not typically a complication of obstructive sleep apnea.
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