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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Changing the catheter once each shift is unnecessary and can increase the risk of infection. Catheters should be replaced only when clinically indicated.

B. Checking the catheter tubing for kinks or twisting is essential to ensure proper drainage and reduce the risk of infection. This action promotes unobstructed urine flow, which is critical for infection prevention.

C. Replacing the catheter every 3 days is not a standard practice; catheters should be changed based on clinical need rather than a set schedule. This could unnecessarily increase the risk of infection.

D. While cleaning the perineal area is important, using an antiseptic solution daily may cause irritation and disrupt the normal flora of the area. Routine cleaning with mild soap and water is typically recommended instead.

A. A client who has right-sided heart failure and 4+ edema to the lower extremities B. A client who is ambulatory following a cardiac catheterization 4 hr ago C. A client who has type 1 diabetes mellitus and is hyperglycemic D. A client who has protein calorie malnutrition E. A client who has postoperative delirium

Correct Answer is ["A","C","D","E"]

Explanation

A. A client with right-sided heart failure and 4+ edema is at risk for pressure ulcers due to fluid accumulation, which can impair circulation and increase the likelihood of skin breakdown.

B. A client who is ambulatory is at a low risk for pressure ulcers because frequent movement reduces the risk of prolonged pressure on any one area.

C. A client with type 1 diabetes mellitus and hyperglycemia is at risk for pressure ulcers because high blood glucose levels can impair wound healing and affect skin integrity.

D. A client with protein-calorie malnutrition is at a significant risk for pressure ulcers due to inadequate nutrition, which weakens the skin and impairs the body’s ability to repair tissue damage.

E. A client with postoperative delirium may have decreased mobility and cognitive awareness, making it harder for them to reposition themselves, thereby increasing their risk of pressure ulcers.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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