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","C","D"]
Explanation
The correct answer isChoice A, Choice C, and Choice D.
Choice A rationale:A shuffling gait can indicate mobility issues, making it difficult for the client to safely perform foot care and toenail clipping. This increases the risk of falls and injuries.
Choice B rationale:Urinary incontinence does not directly affect the ability to perform foot care or toenail clipping. It is more related to bladder control issues.
Choice C rationale:Syncope when bending suggests that the client may experience dizziness or fainting when bending over, making it unsafe for them to perform foot care and toenail clipping.
Choice D rationale:Hand tremors can make it challenging for the client to handle nail clippers or other tools needed for foot care, increasing the risk of injury.
Correct Answer is A
Explanation
Choice A reason: The appearance of a small, round raised area, known as a wheal, is a normal reaction to an intradermal injection and should be documented.
Choice B reason: This is not an allergic response but a normal reaction to an intradermal injection, so there is no need to notify the healthcare provider.
Choice C reason: There is no need to elevate the area or apply pressure as the raised area is a normal reaction to the medication being correctly placed in the dermis.
Choice D reason: Applying a cold pack is not necessary for a normal reaction to an intradermal injection.
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