A client has developed cellulitis as a complication of a pressure ulcer. What action should the nurse prioritize according to the information provided in the text?
"I'll assess the patient's pain level and provide appropriate pain management.".
"I'll encourage frequent position changes and mobility exercises.".
"I'll administer antibiotics to treat the infection.".
"I'll optimize the patient's nutrition and hydration.".
The Correct Answer is C
Choice A rationale:
Assessing the patient's pain level and providing appropriate pain management (Choice A) is important for a patient with cellulitis as a complication of a pressure ulcer.
However, the immediate priority should be to treat the underlying infection with antibiotics (Choice C).
Pain management can be addressed after initiating antibiotic therapy.
Choice B rationale:
Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention for preventing pressure ulcers but may not be the most immediate action needed for a patient with cellulitis.
Treating the infection with antibiotics (Choice C) takes precedence.
Choice C rationale:
Administering antibiotics to treat the infection (Choice C) is the most appropriate nursing action for a client with cellulitis as a complication of a pressure ulcer.
Cellulitis is a bacterial infection that requires prompt antibiotic treatment to prevent its spread and complications.
Choice D rationale:
Optimizing the patient's nutrition and hydration (Choice D) is essential for overall health and wound healing, but in the context of cellulitis, treating the infection (Choice C) is the primary concern.
Once the infection is under control, nutritional support can be addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
The wound's warmth to the touch is not a primary factor to consider when selecting a dressing for a pressure ulcer.
The choice of dressing should primarily be based on the wound's characteristics, such as its depth, exudate level, and tissue involvement.
Choice B rationale:
The presence of a foul odor from the wound is an important factor to consider when selecting a dressing.
Malodorous wounds may indicate infection or necrotic tissue, and appropriate wound dressings can help manage odor and promote healing.
Choice C rationale:
The extent of tissue damage, including muscle and bone involvement, is a critical factor in choosing an appropriate dressing for a pressure ulcer.
Dressings should be selected based on the depth of the wound and the extent of tissue damage to support healing and prevent complications.
Choice D rationale:
The patient's mobility and pressure on vulnerable areas are essential considerations when selecting a dressing.
Dressings should help offload pressure from vulnerable areas and promote mobility while providing optimal wound care.
The choice of dressing should support the overall management of the patient's condition.
Correct Answer is A
Explanation
Choice A rationale:
The nurse is likely to observe warmth around the pressure ulcer site with intact skin.
This is a characteristic clinical manifestation of a stage 1 pressure ulcer.
In stage 1 pressure ulcers, there is non-blanchable erythema (redness) of the skin due to localized inflammation, and the area may feel warm to the touch.
However, the skin is still intact, and there are no open wounds or pus.
Choice B rationale:
This choice is incorrect because the patient described in the question has intact skin, and there is no mention of an open wound with pus.
Pus is typically associated with wound infection, which is not a feature of stage 1 pressure ulcers.
Choice C rationale:
The patient reporting a sharp pain in the affected area is not consistent with the characteristics of a stage 1 pressure ulcer.
Stage 1 pressure ulcers are typically not associated with pain because they only involve the superficial layers of the skin, and the underlying tissues are not affected.
Choice D rationale:
Swelling around the wound is not a typical clinical manifestation of a stage 1 pressure ulcer.
In stage 1, the skin may appear red and feel warm to the touch due to inflammation, but there is no mention of swelling in the question.
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