The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient?
Surgical debridement of the wound
Increased drainage from the wound
Documenting the wound status daily
Increased monitoring of the wound condition
The Correct Answer is A
Choice A rationale
A black pressure ulcer indicates necrotic tissue, which often requires surgical debridement.
Choice B rationale
Increased drainage from the wound is not typically associated with a black pressure ulcer.
Choice C rationale
While documenting the wound status daily is part of wound care, it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.
Choice D rationale
Increased monitoring of the wound condition is part of wound care, but it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Step 1: Calculate the total volume to be infused. Total volume = 250 mL.
Step 2: Calculate the total time for the infusion in minutes. Total time = 2 hours × 60 minutes/hour = 120 minutes.
Step 3: Calculate the flow rate in mL/min. Flow rate = Total volume ÷ Total time = 250 mL ÷ 120 min = 2.08 mL/min.
Step 4: Calculate the flow rate in drops/min. Flow rate = 2.08 mL/min × 15 drops/mL = 31.25 drops/min. So, the nurse should adjust the flow rate to deliver approximately 31 drops per minute.
Correct Answer is C
Explanation
Choice A rationale
Discarding any residual gastric contents before administering the tube feeding is not necessary and could lead to unnecessary loss of nutrients and electrolytes.
Choice B rationale
Positioning the patient in a low Fowler’s position is not the optimal position for administering a tube feeding. The patient should be in an upright position to reduce the risk of aspiration.
Choice C rationale
Testing the pH of the gastric aspirate is an important step before administering a tube feeding. This helps to verify that the feeding tube is in the stomach and not in the lungs.
Choice D rationale
Warming the feeding solution to body temperature is not necessary and could potentially lead to bacterial growth in the feeding solution.
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