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

Choice A rationale:

Auscultation at the pulmonic and mitral points would not provide the clearest hearing of the S2 heart sound. The S2 sound is composed of two components: A2 (aortic valve closure) and P2 (pulmonic valve closure). The aortic valve sound (A2) is usually louder than P2. Mitral point is not ideal for hearing S2 clearly, as it's mostly associated with S1 sound.

Choice B rationale:

The tricuspid and aortic points are the most appropriate for hearing the S2 heart sound. The aortic valve (A2) is best heard at the second right intercostal space close to the sternum, and the tricuspid valve is best heard at the lower left sternal border.

Choice C rationale:

While the mitral and tricuspid points are important for auscultating the heart sounds, they are more associated with the S1 sound (the first heart sound). The S2 sound is best heard at the aortic and pulmonic areas.

Choice D rationale:

The aortic and pulmonic points are important for assessing the S2 heart sound, but they are not the most optimal locations. The aortic valve sound is heard most clearly at the second right intercostal space, whereas the pulmonic valve sound is heard at the second left intercostal space.

A. Reposition the client every 3 hours. B. Massage bony prominences to promote circulation. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry.

Correct Answer is A

Explanation

Choice A rationale:

Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown in older adults who are immobile or have limited mobility. Prolonged pressure on certain areas can lead to ischemia and tissue damage, particularly over bony prominences. Repositioning helps to distribute pressure evenly, maintain circulation, and reduce the risk of pressure ulcers.

Choice B rationale:

Massage of bony prominences is not recommended as a preventive measure for skin breakdown. Massaging these areas can actually cause friction and shear forces, leading to further damage to the delicate skin of older adults. Gentle repositioning and maintaining proper skin hygiene are more effective strategies.

Choice C rationale:

While a diet high in protein is important for overall health, it is not a direct intervention for maintaining the integrity of the client's skin. Protein is necessary for wound healing and tissue repair, but it doesn't address the primary concern of preventing skin breakdown due to pressure.

Choice D rationale:

Applying cornstarch to keep the skin dry is not a recommended practice for preventing skin breakdown. Excessive moisture can contribute to skin breakdown, but cornstarch may not be the best solution. Proper hygiene, gentle cleansing, and appropriate use of moisture-barrier products are more effective in maintaining skin integrity.

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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

A Medical-Surgical nurse is assessing a client's heart sounds. In which of the following points of auscultation would the nurse hear the S2 sound most clearly?

Correct Answer is B

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is A

Explanation

A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

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