A client presents with a pressure ulcer and signs of infection. Which nursing action aligns with the information in the text?
"I'll consult with the healthcare team to address underlying medical conditions.".
"I'll encourage frequent position changes and mobility exercises.".
"I'll use specialized mattresses to offload pressure.".
"I'll provide education on proper wound care and prevention strategies.".
The Correct Answer is A
Choice A rationale:
Consulting with the healthcare team to address underlying medical conditions (Choice A) is the most appropriate nursing action for a client with a pressure ulcer and signs of infection.
Pressure ulcers can develop or worsen due to underlying medical conditions such as diabetes, vascular disease, or immunosuppression.
Addressing these underlying conditions is essential for effective wound management and preventing further complications.
Choice B rationale:
Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention to prevent pressure ulcers, but in a client with an existing pressure ulcer and signs of infection, addressing the infection and underlying medical conditions take precedence.
Choice C rationale:
Using specialized mattresses to offload pressure (Choice C) is an important part of pressure ulcer prevention and management, but it may not be the most immediate action needed for a client with signs of infection.
Addressing infection and underlying medical conditions (Choice A) should be the priority.
Choice D rationale:
Providing education on proper wound care and prevention strategies (Choice D) is an essential nursing action but may not be the most immediate priority for a client with an active infection.
Managing the infection and addressing underlying medical conditions (Choice A) should come first.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
"Advanced age is the primary risk factor for pressure ulcers in individuals with diabetes." While advanced age is a risk factor for pressure ulcers, it is not the primary risk factor in individuals with diabetes.
Diabetes itself presents several risk factors, including compromised blood flow and oxygenation, which increase the susceptibility to pressure ulcers.
Choice B rationale:
"Sensory deficits in diabetes make patients more resistant to pressure ulcers." This statement is incorrect.
Sensory deficits in diabetes, such as neuropathy, make patients more vulnerable to pressure ulcers.
These deficits can lead to reduced awareness of discomfort or pain, allowing pressure to be applied to areas without the patient's awareness.
Choice C rationale:
"Poor nutrition and hydration do not contribute to the development of pressure ulcers in diabetic patients." This statement is not accurate.
Poor nutrition and hydration can significantly contribute to the development of pressure ulcers in diabetic patients.
Adequate nutrition and hydration are essential for maintaining skin integrity and supporting the healing process.
Choice D rationale:
"Individuals with diabetes are more prone to pressure ulcers due to compromised blood flow and oxygenation." This statement is correct.
Diabetes can lead to compromised blood flow (peripheral vascular disease) and oxygenation (due to vascular damage), making individuals with diabetes more prone to pressure ulcers.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
"Frequent repositioning of the patient." Frequent repositioning is crucial in preventing pressure ulcers.
It helps redistribute pressure on vulnerable areas, reducing the risk of tissue ischemia and damage.
Choice B rationale:
"Maintaining a dry and clean skin surface." Keeping the skin clean and dry is essential in preventing pressure ulcers.
Moisture can contribute to skin breakdown, so maintaining dryness helps preserve skin integrity.
Choice C rationale:
"Applying pressure-relieving cushions or devices." Using pressure-relieving cushions or devices can help distribute pressure more evenly and reduce the risk of pressure ulcers in bedridden patients.
Choice D rationale:
"Increasing the intake of sugar-rich foods." This choice is not appropriate for preventing pressure ulcers.
Increasing sugar-rich foods can lead to complications such as diabetes and should not be a part of pressure ulcer prevention strategies.
Choice E rationale:
"Encouraging immobility in bedridden patients." Encouraging immobility is not a recommended strategy for preventing pressure ulcers.
Immobility increases the risk of pressure ulcers, and caregivers should aim to promote mobility and reposition patients regularly.
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