A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. No drainage is noted. The nurse would treat the area with which dressing to promote healing?
Wet to dry dressing
No dressing is needed
Hydrocolloid dressing
Alginate
The Correct Answer is C
A. A wet-to-dry dressing is typically used for debridement and is not appropriate for a shallow pressure ulcer without necrotic tissue, as it can damage healthy tissue during dressing changes.
B. Leaving the area without a dressing is not advisable as it exposes the wound to contaminants and increases the risk of infection; a dressing should be used to protect the area.
C. A hydrocolloid dressing is ideal for shallow partial-thickness wounds as it provides a moist environment, promotes healing, and helps to cushion the area while maintaining a barrier against bacteria.
D. Alginate dressings are primarily used for wounds with moderate to heavy exudate and would not be suitable in this case due to the lack of drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Limiting activity can contribute to constipation, so the nurse should encourage regular physical activity to promote bowel function.
B. Drinking four to five glasses of water daily is insufficient; older adults typically need at least 6-8 glasses to help prevent constipation.
C. Increasing dietary intake of raw vegetables provides fiber, which is essential for promoting bowel regularity and preventing constipation. This recommendation aligns with dietary guidelines for improving gastrointestinal health.
D. Bearing down hard when defecating can lead to complications such as hemorrhoids or valsalva maneuvers, so clients should be taught to relax and allow for a natural bowel movement instead.
Correct Answer is B
Explanation
A. Emptying the pouch when it becomes 1/3 full is appropriate and helps prevent leakage and odor. This statement shows understanding of proper pouch management.
B. Enteric-coated medications can be problematic for clients with an ileostomy as they may not dissolve properly in the digestive system, potentially leading to decreased absorption. The client should be aware that these medications may not be suitable for their condition.
C. Changing the entire pouch system at least weekly is a common recommendation to maintain hygiene and skin integrity. This indicates the client understands the need for regular pouch maintenance.
D. Caution when eating high-fiber foods is important, as these foods can cause blockages in the ileostomy. This statement reflects the client’s awareness of dietary considerations for managing their ileostomy.
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