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 B

Explanation

A. Enteral feeding, while important, can wait momentarily if the client's airway needs immediate attention.
B. Endotracheal suctioning is a priority if the client is having difficulty breathing or has excessive secretions in the airway.
C. Wound irrigation can be performed after ensuring the client's airway is clear and stable.
D. Urinary catheter care is important but can be prioritized after addressing acute respiratory needs.

A. Check the unit of blood with an assistant personal (AP). B. Plan to infuse the unit of blood over 6 hr. C. Remain with the client for the first 15 minutes of the transfusion. D. Pre-medicate the client with an antiemetic.

Correct Answer is C

Explanation

A. The blood must be checked by two licensed professionals, not an assistant personal (AP).
B. Blood should be infused within 4 hours to reduce the risk of bacterial contamination.
C. The nurse should remain with the client for the first 15 minutes of the transfusion to monitor for any immediate adverse reactions.
D. Pre-medicating with an antiemetic is not a standard practice unless specifically indicated by the client's history or condition.

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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 prioritizing care for a client. Which of the following procedures should the nurse perform first?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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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

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?

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