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: Giving water may be necessary, but it is not the first intervention if there is a concern about urinary output.

Choice B reason: Notifying the healthcare provider is important but should occur after initial assessments and interventions.

Choice C reason: Checking for a kink in the drainage tubing is a quick and simple intervention that may resolve the issue of low output.

Choice D reason: Reviewing the intake and output record is important for understanding the patient's fluid status but is not the first action to take in this situation.

A. Obtain the specimen from the client's current bowel movement. B. Contact the healthcare provider before obtaining the specimen. C. Wait to obtain the specimen until observable blood is present. D. Withhold specimen collection until tarry black stool is observed.

Correct Answer is A

Explanation

Choice A reason: The presence of soft, formed, and light brown feces is normal and does not preclude testing for occult blood. The nurse should proceed with obtaining the specimen as ordered.
Choice B reason: There is no need to contact the healthcare provider before obtaining the specimen if the stool appears normal and the test for occult blood has been ordered.
Choice C reason: Waiting for observable blood is not necessary for an occult blood test, which is designed to detect blood that is not visible to the naked eye.
Choice D reason: Withholding specimen collection until tarry black stool is observed is not indicated. Tarry black stool can indicate bleeding in the upper gastrointestinal tract, but the test for occult blood is used to detect blood that may not be visible in the stool. Bolded text indicates the correct answers and important information.

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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

The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, formed, and light brown. Which action should the nurse implement?

Correct Answer is A

Explanation

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Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.