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:
Incorrect. The kidneys do play a role in acid-base balance, but they primarily eliminate acids other than carbon dioxide. They do not significantly convert carbon dioxide for elimination.
Elaboration: While the kidneys help regulate acid-base balance through reabsorption and excretion of bicarbonate and hydrogen ions, their role in carbon dioxide elimination is minimal. They primarily excrete acids like uric acid, phosphoric acid, and lactic acid.
Choice B rationale:
Incorrect. Hyperventilation would decrease carbon dioxide levels, not contribute to respiratory acidosis. Respiratory acidosis is characterized by elevated carbon dioxide levels.
Elaboration: Hyperventilation leads to rapid and excessive breathing, causing a decrease in carbon dioxide levels in the blood. This can result in respiratory alkalosis, not respiratory acidosis.
Choice C rationale:
Correct. Respiratory acidosis is caused by the accumulation of carbon dioxide in the blood. This can happen due to impaired ventilation, such as in conditions like chronic obstructive pulmonary disease (COPD), pneumonia, or respiratory failure.
Elaboration: Carbon dioxide is produced as a byproduct of cellular metabolism. It is normally removed from the body through exhalation. When ventilation is impaired, carbon dioxide cannot be efficiently eliminated, leading to its buildup in the blood. This excess carbon dioxide reacts with water to form carbonic acid, lowering blood pH and causing respiratory acidosis.
Choice D rationale:
Incorrect. Low blood oxygen levels (hypoxemia) can stimulate the respiratory rate, but this would not directly cause respiratory acidosis. It might lead to hyperventilation, which could potentially cause respiratory alkalosis.
Elaboration: The body's respiratory center in the brainstem regulates breathing based on blood oxygen and carbon dioxide levels. Hypoxemia triggers a compensatory increase in respiratory rate to enhance oxygen intake. However, this response does not directly contribute to respiratory acidosis.
Correct Answer is D
Explanation
Rationale for Choice A: Dysrhythmia
There is no information in the question stem to suggest that the patient is experiencing a dysrhythmia.
Dysrhythmias are abnormal heart rhythms that can be caused by a variety of factors, including heart disease, electrolyte imbalances, and medications.
While it is possible that the patient could develop a dysrhythmia as a complication of pneumonia, there is no evidence to support this in the given information.
Additionally, enalapril, which the patient is taking for hypertension, is not typically associated with an increased risk of dysrhythmias.
Rationale for Choice B: Toxicity
There is no information in the question stem to suggest that the patient is experiencing toxicity.
Toxicity can be caused by a variety of substances, including medications, drugs, and environmental toxins.
While it is possible that the patient could develop toxicity as a complication of pneumonia, there is no evidence to support this in the given information.
Additionally, the patient's medication regimen of enalapril and a multivitamin is not typically associated with an increased risk of toxicity.
Rationale for Choice C: Anemia
There is no information in the question stem to suggest that the patient is anemic.
Anemia is a condition in which there is a decreased number of red blood cells or hemoglobin in the blood.
While it is possible that the patient could develop anemia as a complication of pneumonia, there is no evidence to support this in the given information.
Additionally, the patient's surgical history of adenoid removal and a fractured tibia is not typically associated with an increased risk of anemia.
Rationale for Choice D: Pneumonia
The patient is a 51-year-old male with a diagnosis of pneumonia.
Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi.
The patient's symptoms, such as cough, fever, and difficulty breathing, are all consistent with a diagnosis of pneumonia.
Additionally, the patient's medical history of hypertension does not rule out pneumonia, and in fact, some studies have shown that hypertension may be a risk factor for developing pneumonia.
Therefore, pneumonia is the most likely condition that the patient has based on the information provided.
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