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 D
Explanation
The correct answer is choice D. Reported history of alcoholism.
Choice A rationale:
Employment as a construction worker is not directly relevant to the administration of terbinafine HCL. While it may affect the client’s overall health and risk of injury, it does not impact the medication’s safety or efficacy.
Choice B rationale:
A white blood cell count of 8,500/mm³ (8.5 x 10³/L) is within the normal range and does not indicate any immediate concern that would affect the administration of terbinafine HCL.
Choice C rationale:
Thick and yellow toenails are typical symptoms of a fungal toenail infection and are the reason for prescribing terbinafine HCL. This finding confirms the diagnosis but does not present a contraindication to the medication.
Choice D rationale:
A reported history of alcoholism is crucial to address because terbinafine HCL can cause liver toxicity. Clients with a history of alcoholism are at higher risk for liver damage, and this must be carefully evaluated before starting the medication.
Correct Answer is B
Explanation
Choice A rationale:
Hypothermia is a condition in which the body's core temperature falls below 95°F (35°C). It is not directly indicated by the client's vital signs as presented in the question.
Other factors that would more strongly suggest hypothermia include exposure to cold environments, immersion in cold water, or impaired thermoregulation due to conditions like hypothyroidism or alcohol intoxication.
Choice C rationale:
Hypotension is a condition in which blood pressure is abnormally low. It is also not directly indicated by the client's vital signs as presented in the question.
Hypertension, on the other hand, is a condition in which blood pressure is abnormally high.
The client's history of hypertension, and the fact that he takes enalapril (an antihypertensive medication), suggests that he may be more likely to experience hypertension than hypotension.
Choice D rationale:
Hypertension, as mentioned above, is a condition in which blood pressure is abnormally high.
While it's possible that the client is experiencing hypertension, the question specifically asks about the condition indicated by the client's vital signs.
Tachypnea, or rapid breathing, is a more direct indication of the client's respiratory distress, which is a common symptom of pneumonia.
Choice B rationale:
Tachypnea is the most likely condition indicated by the client's vital signs.
Tachypnea is often a sign of respiratory distress, which can be caused by a variety of conditions, including pneumonia. When a person has pneumonia, their lungs become inflamed and filled with fluid, making it difficult to breathe.
This can lead to rapid, shallow breathing, which is called tachypnea.
Other signs of respiratory distress that may be present in a client with pneumonia include: Coughing
Wheezing Chest pain
Feeling short of breath
Use of accessory muscles to breathe (e.g., muscles in the neck and chest) Nasal flaring
Cyanosis (a bluish tint to the skin)
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