The nurse is performing a routine dressing change for a patient 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.
Apply a hydrocolloidal gel dressing.
Increase the frequency of the dressing changes.
Replace the gauze with a transparent dressing.
The Correct Answer is B
Choice A rationale:
Leaving the dressing off would expose the wound to air and potential contamination, which could delay healing and increase the risk of infection.
While consulting with the healthcare provider is always an option, it's not necessary in this case as the nurse has the knowledge and skills to select an appropriate dressing.
Additionally, leaving the wound uncovered could cause pain and discomfort to the patient, as well as potentially disrupt the delicate granulation tissue that has already formed.
Choice C rationale:
Increasing the frequency of dressing changes could disrupt the healing process and irritate the wound bed.
It's generally recommended to change dressings only as often as necessary to keep the wound clean and moist. Excessive dressing changes can also be costly and time-consuming for both the patient and the healthcare provider. Choice D rationale:
Transparent dressings are not ideal for stage 3 pressure injuries with significant granulation tissue. These dressings are more suitable for wounds with minimal exudate and that are not actively healing. Transparent dressings can also adhere to the wound bed, causing pain and trauma upon removal.
Choice B rationale:
Hydrocolloidal gel dressings are a good choice for stage 3 pressure injuries with granulation tissue because they: Provide a moist wound environment, which promotes healing.
Absorb exudate, which helps to prevent maceration of the surrounding skin. Form a protective barrier over the wound, which helps to prevent infection.
Are comfortable for the patient and can be left in place for several days.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Sterile gloves are not necessary for routine oral care, even in the presence of oral Candida albicans.
Standard precautions, which include the use of gloves, are sufficient to protect the UAP from exposure to blood and body fluids.
Sterile gloves would only be indicated for invasive procedures, such as oral surgery or deep tissue sampling.
Choice B rationale:
Delegating oral care to the UAP is appropriate, as it is a routine task that does not require the specialized skills of a nurse.
The nurse should provide clear instructions to the UAP on how to perform oral care, but it is not necessary for the nurse to complete the task themselves.
Choice C rationale:
Using a soft-bristled toothbrush is important for patients with oral Candida albicans, as it can help to remove plaque and debris without further irritating the delicate tissues of the mouth.
A soft-bristled toothbrush is less likely to cause bleeding or pain than a harder-bristled toothbrush.
Choice D rationale:
Mouthwash is not typically recommended for patients with oral Candida albicans, as it can actually dry out the mouth and worsen symptoms.
In some cases, a healthcare provider may prescribe a special antifungal mouthwash, but this should only be used under their supervision.
Correct Answer is A
Explanation
Choice A rationale:
Hemoglobin A1C (HbA1C) is a blood test that reflects a person's average blood glucose levels over the past 2-3 months. It's considered the gold standard for diagnosing and monitoring diabetes.
An HbA1C level of 8.29% is significantly elevated above the reference range of 4-5.99%, indicating a high probability of diabetes.
The patient's HbA1C has also increased from 7.59% three months ago, suggesting a worsening of glycemic control.
Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose levels due to impaired insulin production or action, or both.
Common symptoms of diabetes include increased thirst, frequent urination, fatigue, blurred vision, and slow-healing wounds.
Early diagnosis and treatment of diabetes are crucial to prevent complications such as heart disease, stroke, kidney disease, nerve damage, and vision loss.
Choice B rationale:
Hypoglycemia refers to abnormally low blood glucose levels, typically below 70 mg/dL. It's often caused by excessive insulin or medication, missed meals, or strenuous exercise.
The patient's HbA1C level of 8.29% does not support a diagnosis of hypoglycemia.
Choice C rationale:
Hyperglycemia refers to abnormally high blood glucose levels, typically above 180 mg/dL. It can be caused by diabetes, stress, infection, or certain medications.
While the patient's HbA1C level does indicate hyperglycemia, it's specifically the pattern of elevated HbA1C over time that points to a diagnosis of diabetes mellitus, rather than transient hyperglycemia.
Choice D rationale:
Prediabetes is a condition where blood glucose levels are higher than normal, but not high enough to be classified as diabetes. People with prediabetes are at increased risk of developing diabetes.
The patient's HbA1C level of 8.29% is above the threshold for prediabetes, which is typically 5.7-6.4%.
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