Which technique is most appropriate for a nurse to use when cleansing a pressure ulcer?
Cleanse using hydrogen peroxide followed by betadine solution.
Cleanse the wound gently from the outer edges towards the center.
Cleanse using 4x4 gauze to the wound and surrounding skin three times.
Cleanse from the innermost point outwards with a circular movement.
The Correct Answer is D
Cleanse from the innermost point outwards with a circular movement. This technique reduces the risk of contaminating the wound with bacteria from the surrounding skin.
Some possible explanations for the other choices are:
Choice A is wrong because hydrogen peroxide and betadine solution can damage healthy tissue and delay wound healing.
Choice B is wrong because cleansing the wound from the outer edges towards the center can introduce bacteria from the skin into the wound.
Choice C is wrong because using 4x4 gauze to the wound and surrounding skin three times can cause trauma and bleeding to the wound.
Normal ranges for pressure ulcer stages are:
- Stage I: A reddened, painful area on the skin that does not turn white when pressed.
- Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
- Stage III: The skin develops an open, sunken hole called a crater or ulcer. The tissue below the skin is damaged.
- Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Reminiscing about the spouse with significant others. This is an important need for a widowed client during the grieving period following the death of the client’s spouse because it helps them process their loss, express their emotions, and honor their memories. Reminiscing can also provide comfort, support, and meaning to the bereaved.
Choice B. Self-indulgence in order to fill the emptiness left by the spouse’s death is wrong because it can be unhealthy, addictive, or harmful to the client’s well-being. Self-indulgence may also prevent the client from coping with their grief in a constructive way.
Choice C. Reassurance that the client did all that could be expected for their spouse is wrong because it may imply that the client is responsible for their spouse’s death or that they could have prevented it.
This may increase the client’s guilt, regret, or self-blame. Reassurance should focus on the client’s strengths, resilience, and coping skills.
Choice D. Engagement in activities that will take the client’s mind off the loss of the spouse is wrong because it may suggest that the client should avoid or deny their grief.
This may interfere with the healing process and lead to unresolved or complicated grief. Engagement in activities should be balanced with time for reflection, mourning, and self-care.
Normal ranges for grief vary depending on the individual, the relationship, and the circumstances of the death. However, some general guidelines are that grief can last from a few months to several years and that it may involve physical and emotional symptoms such as trouble sleeping, loss of appetite, difficulty concentrating, crying, sadness, anger,
Correct Answer is B
Explanation
Sensory deprivation is a condition in which a person experiences a lack of sensory input or stimulation.
This can result from isolation, confinement, or loss of sensory function. Sensory deprivation can cause psychological and physiological changes, such as irritability, confusion, paranoia, hallucinations, depression, anxiety, and cognitive impairment.
Choice A is wrong because mood disorder is a general term for a group of mental health conditions that affect a person’s emotional state, such as depression, bipolar disorder, or anxiety disorder. Mood disorder is not likely to be caused by isolation precautions for C diff.
Choice C is wrong because anxiety is a feeling of nervousness, worry, or fear that interferes with daily functioning. Anxiety can be triggered by stress, trauma, or other factors, but it is not a direct consequence of isolation precautions for C diff.
Choice D is wrong because cerebral vascular accident (CVA), also known as stroke, is a sudden interruption of blood flow to the brain that causes neurological damage. CVA can cause symptoms such as weakness, numbness, slurred speech, vision loss, or confusion, but it is not related to isolation precautions for C diff.
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