A chronically ill, bedfast patient cared for in the home by family members has a stage II pressure ulcer over the coccyx. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to

Provide the patient with a high-calorie, high-protein diet.

Change the patient's position every 2 hours, avoiding the supine position.

Change the patient's linen daily.

Record the size and appearance of the ulcer daily.

Answer and Explanation

The Correct Answer is B

A. While a high-calorie, high-protein diet is beneficial for wound healing, it is not the most critical factor in preventing further tissue damage.
B. Changing the patient's position every 2 hours is crucial to relieve pressure on the ulcer and prevent further tissue damage.
C. Changing the patient's linen daily is important for hygiene but does not directly prevent pressure ulcer progression.
D. Recording the size and appearance of the ulcer is important for monitoring, but preventing further damage through repositioning is more critical.

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Correct Answer is C

Explanation

A. The maturation phase is the final phase of wound healing and involves the strengthening and remodeling of collagen fibers.
B. The proliferation phase is the second phase of wound healing, characterized by the formation of new tissue and blood vessels.
C. The inflammation phase is the first phase of wound healing, during which the body's initial response to injury involves hemostasis and inflammation. This phase includes vasodilation, increased permeability of blood vessels, and the influx of white blood cells to clean the wound.
D. The remodeling phase is another term for the maturation phase, the final phase of wound healing.

A. Physician assistant B. Physical therapist C. Occupational therapist D. Social worker

Correct Answer is C

Explanation

A. Physician assistants typically assist with medical diagnoses and treatment plans, not rehabilitation.
B. Physical therapists focus on physical movement and rehabilitation, not typically assisting with activities of daily living such as feeding.
C. Occupational therapists specialize in helping individuals with daily activities, making them the appropriate referral for this client's needs.
D. Social workers typically provide assistance with psychosocial support and community resources, which may be needed but are not as directly related to the client's physical limitations.

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A chronically ill, bedfast patient cared for in the home by family members has a stage II pressure ulcer over the coccyx. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to teach a group of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse plan to discuss?

Correct Answer is C

Explanation

A nurse is caring for a client who has severe rheumatoid arthritis in her hands and is unable to feed herself. For which of the following health care team members should the nurse request a referral from the provider?

Correct Answer is C

Explanation

Which of the following are examples of low-risk complementary and alternative therapies that nurses can use with their clients?

A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following?

The nurse accidentally administers 15 mg of morphine IM to a client who had been given another dose of morphine 15 mg IM about 30 minutes earlier. What action should the nurse be prepared to take?

A chronically ill, bedfast patient cared for in the home by family members has a stage II pressure ulcer over the coccyx. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to

A client with an aortic valve replacement is taking a daily dose of warfarin to prevent clot formation. The client states that he is also taking ginkgo biloba to Improve his memory and concentration. What would be the nurse's best response?

The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?