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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["38"]

Explanation

Here are the steps to calculate the IV flow rate:

Step 1: Calculate the volume to be infused per minute.

75 mL ÷ 30 minutes = 2.5 mL/minute

Step 2: Multiply the volume per minute by the drop factor to determine the drops per minute.

2.5 mL/minute × 15 gtt/mL = 37.5 gtt/minute

Step 3: Round the answer to the nearest whole number. The nurse should regulate the IV to deliver 38 gtt/minute.

A. Chronic pain related to tissue destruction by tumor. B. Anxiety and grieving related to progression of disease. C. Risk for aspiration related to difficulty swallowing. D. Imbalanced nutrition: less than body requirements.

Correct Answer is C

Explanation

Choice A rationale:

Chronic pain is a significant concern for this client, but it is not the immediate priority. Pain can be managed with medications and comfort measures, while aspiration can be life-threatening.

Tissue destruction by the tumor is likely contributing to the pain, but addressing the risk of aspiration takes precedence.

Uncontrolled pain can exacerbate anxiety and make it difficult to focus on other interventions, but ensuring airway safety is paramount.

Choice B rationale:

Anxiety and grieving are expected reactions to a diagnosis of esophageal cancer, and they should be addressed as part of the client's care plan. However, they are not the immediate priority in this case.

The progression of the disease is a significant stressor, but attending to the risk of aspiration is essential for the client's safety. Psychological distress can negatively impact coping and quality of life, but addressing physical needs takes precedence.

Choice D rationale:

Imbalanced nutrition is a concern for this client due to dysphagia and anorexia. However, it is not the immediate priority. Nutritional interventions can be implemented once the risk of aspiration is addressed.

Difficulty swallowing can lead to inadequate intake and malnutrition, but ensuring airway safety is the primary concern.

Anorexia can further contribute to nutritional deficits, but preventing aspiration is the most pressing issue.

Choice C is the priority nursing problem because:

The client's dysphagia puts them at immediate risk for aspiration, which can lead to pneumonia, respiratory failure, and even death.

Addressing the risk of aspiration is essential to ensure the client's safety and prevent life-threatening complications. It's crucial to implement interventions to minimize the risk of aspiration, such as:

Elevating the head of the bed during meals and for 30-60 minutes after eating Thickening liquids and pureeing foods

Encouraging small, frequent meals

Monitoring for signs of aspiration, such as coughing, choking, or difficulty breathing

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 ml of D5W to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["38"]

Explanation

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer.The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

Correct Answer is C

Explanation

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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?