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 B
Explanation
A Colloidal oatmeal-based lotion: Colloidal oatmeal can help to reduce itching and swelling, all while hydrating the skin. It is often used to soothe irritated skin and can be incorporated into a skincare routine through oatmeal baths or oatmeal-infused moisturizers. However, it is typically used as a complementary treatment and may not be sufficient to manage psoriasis symptoms on its own.
B Topical corticosteroids: These are an essential tool for treating inflammatory skin conditions such as psoriasis34. They work by reducing inflammation and slowing down the production of skin cells, which helps to alleviate symptoms such as redness, itching, and scaling. Topical corticosteroids are often the first line of treatment for mild to moderate psoriasis.
C. Topical analgesics: These are primarily used to relieve pain. While they may provide some relief from discomfort associated with psoriasis, they do not address the underlying inflammation and rapid skin cell production that characterize this condition.
D Topical antifungal: Antifungal agents are typically used to treat conditions like seborrheic dermatitis and scalp psoriasis, or in areas where psoriasis involves folds in the skin, where there is an increased potential for localized infection. However, they are not typically used as a primary treatment for psoriasis.
Correct Answer is B
Explanation
Step 1: Identify the desired dose and the available concentration. Desired dose: 500 mg of vancomycin
Available concentration: 500 mg per 100 ml
Step 2: Determine the volume needed to deliver the desired dose.
Since the available concentration is 500 mg per 100 ml, no further calculation is required. The volume needed to deliver 500 mg of vancomycin is already 100 ml.
Step 3: Calculate the infusion rate in mL/hr.
The medication needs to be administered over 1 hour.
Therefore, the infusion pump should be set to deliver the 100 ml of solution over 1 hour. Infusion rate = 100 ml / 1 hour = 100 mL/hr.
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