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When giving a hot soak treatment, it is most important to:

Test the temperature of the solution.

Use only sterile equipment and solution.

Position the patient comfortably.

Soak only the affected area.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Testing the temperature of the solution is crucial to prevent burns.

Choice B rationale:

While using sterile equipment and solution is important, it’s not the most important in a hot soak treatment.

Choice C rationale:

Comfort is important but not as critical as preventing burns.

Choice D rationale:

Soaking only the affected area is good practice but not as vital as preventing burns.

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Correct Answer is C

Explanation

Choice A rationale:

Stage 1 pressure ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice B rationale:

Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice C rationale:

Stage 2 pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale:

Stage 4 pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

A. A client who is alert and responsive and eats 25% of each meal. B. A client who is unresponsive to verbal commands and changes position occasionally. C. A client who makes frequent slight changes in position and walks occasionally. D. A client who is receiving enteral feeding and can change position independently.

Correct Answer is B

Explanation

Choice A rationale:

An alert and responsive client who eats 25% of each meal may have nutritional deficiencies, but is able to change position to relieve pressure.

Choice B rationale:

A client who is unresponsive to verbal commands and only changes position occasionally is at high risk for pressure injury due to prolonged pressure on certain areas of the body.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is not at high risk for pressure injury.

Choice D rationale:

A client receiving enteral feeding and can change position independently is not at high risk for pressure injury.

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When giving a hot soak treatment, it is most important to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

Correct Answer is C

Explanation

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

Correct Answer is B

Explanation

Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal.The nurse would change the dressing procedure in order to use:

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a:

The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

A nurse is preparing to assist with irrigating a wound for a client.Which of the following actions should the nurse plan to take?

The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed.The nurse's most beneficial intervention would be to:

The nurse is performing a dry sterile dressing change for an abdominal wound.The nurse should use a swab to clean:

The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.