A Medical-Surgical nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Clean the wound by scrubbing the site with gauze.

Massage reddened areas with dressing changes.

Reposition the client at least every 2 hours.

Apply a heat lamp twice a day.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Cleaning the wound by scrubbing the site with gauze is not an appropriate intervention for a stage 3 pressure ulcer. Scrubbing can damage the fragile tissue, increase the risk of infection, and delay wound healing. Gentle cleaning with a mild solution and avoiding trauma to the wound bed are recommended.

Choice B rationale:

Massaging reddened areas with dressing changes is contraindicated for pressure ulcers, especially stage 3 ulcers. Massaging can cause further damage to the tissues and disrupt the healing process. Dressing changes should focus on maintaining a clean and moist environment to promote healing.

Choice C rationale:

(Correct Choice) Repositioning the client at least every 2 hours is a crucial intervention to prevent further pressure ulcers and facilitate wound healing. Regular repositioning helps relieve pressure on specific areas and improves blood circulation, reducing the risk of tissue breakdown and the development of new ulcers.

Choice D rationale:

Applying a heat lamp twice a day is not recommended for stage 3 pressure ulcers. Heat can increase blood flow to the area, potentially exacerbating inflammation and delaying healing. Pressure ulcers require a clean and moist environment for optimal healing.

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Correct Answer is B

Explanation

A. Autonomy:This principle refers to respecting a patient's right to make their own decisions about their healthcare. In this scenario, the nurse's actions did not directly impact the client's autonomy, as the client was not involved in the decision-making process regarding the incident report.

B. Veracity:This principle involves being truthful and transparent. By not completing an incident report, the nurse failed to uphold veracity, as this action concealed the truth about the medication error, potentially affecting future care and trust in the healthcare system.

C. Confidentiality:This principle is about protecting patient information. The nurse's failure to report the incident did not violate confidentiality, as it did not involve disclosing or mishandling the client's private information.

D. Beneficence:This principle focuses on doing good and acting in the best interest of the patient. While the nurse's intention might have been to avoid unnecessary alarm, failing to report the incident could prevent the healthcare team from learning from the mistake and improving patient safety, thus indirectly affecting beneficence.

A. Encourage the client to ambulate frequently. B. Encourage the client to increase fluid intake. C. Encourage regular use of the incentive spirometer. D. Encourage coughing and deep breathing.

Correct Answer is C

Explanation

Choice A rationale:

Encouraging the client to ambulate frequently is important for preventing complications associated with immobility, such as deep vein thrombosis and muscle atrophy. However, it is not a direct intervention for promoting the thinning of respiratory secretions.

Choice B rationale:

Encouraging the client to increase fluid intake is a valuable intervention to help thin respiratory secretions. However, the most effective method mentioned here is the use of the incentive spirometer, which directly assists the client in taking deep breaths and enhancing lung function.

Choice C rationale:

Encouraging regular use of the incentive spirometer is a crucial intervention for promoting the thinning of respiratory secretions. Incentive spirometry helps prevent atelectasis (collapse of lung tissue) and promotes deep breathing, which aids in clearing secretions and maintaining lung health.

Choice D rationale:

Encouraging coughing and deep breathing is generally important for maintaining lung health and preventing complications like pneumonia. However, the specific action of using the incentive spirometer is more targeted and effective for promoting respiratory secretion clearance in clients with pneumonia.

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A Medical-Surgical nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

Correct Answer is C

Explanation

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