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A nurse is assessing a patient at risk for pressure ulcers. Which interventions are appropriate for preventing pressure ulcers based on the information in the text?(Select all that apply)

"Optimize nutrition and hydration.".

"Administer antibiotics prophylactically.".

"Promote mobility and activity.".

"Use appropriate support surfaces and equipment.".

"Educate patients, caregivers, and healthcare professionals on prevention strategies.".

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:

Optimizing nutrition and hydration (Choice A) is a crucial intervention for preventing pressure ulcers.

Proper nutrition supports tissue health and wound healing.

Dehydration and malnutrition can increase the risk of developing pressure ulcers or exacerbate existing ones.

Choice B rationale:

Administering antibiotics prophylactically (Choice B) is not a routine intervention for preventing pressure ulcers.

Antibiotics should be used to treat infections when they occur but should not be given prophylactically unless there are specific clinical indications.

Choice C rationale:

Promoting mobility and activity (Choice C) is an effective strategy for preventing pressure ulcers.

Regular position changes and mobility exercises help relieve pressure on vulnerable areas of the skin, reducing the risk of pressure ulcers.

Choice D rationale:

Using appropriate support surfaces and equipment (Choice D) is essential for preventing pressure ulcers in patients at risk.

Support surfaces, such as pressure-reducing mattresses, can help distribute pressure evenly and reduce the risk of tissue damage.

Choice E rationale:

Educating patients, caregivers, and healthcare professionals on prevention strategies (Choice E) is a vital component of pressure ulcer prevention.

Proper education helps raise awareness and ensures that everyone involved in patient care understands the importance of preventive measures.

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Correct Answer is C

Explanation

Choice A rationale:

"The client's advanced age is the primary factor affecting wound healing." While advanced age can affect wound healing, it is not the primary factor in this case.

The client's history of vascular disease is a more significant contributing factor.

Choice B rationale:

"The client's wound is not adequately protected from friction." Friction can impact wound healing, but in this case, vascular disease plays a more substantial role in impaired wound healing.

Choice C rationale:

"Vascular disease may lead to compromised blood flow and oxygenation in the affected area." This statement is correct.

Vascular disease can impair blood flow and oxygenation to tissues, significantly affecting wound healing.

Reduced blood flow deprives tissues of necessary nutrients and oxygen, leading to delayed healing.

Choice D rationale:

"The client's wound healing process is delayed due to a hyperactive immune response." A hyperactive immune response is not typically a primary factor in impaired wound healing associated with vascular disease.

The primary concern in vascular disease is compromised blood flow and tissue perfusion.

A. The wound's warmth to the touch. B. The presence of foul odor from the wound. C. The extent of tissue damage, including muscle and bone involvement. D. The patient's mobility and pressure on vulnerable areas.

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.

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A nurse is assessing a patient at risk for pressure ulcers. Which interventions are appropriate for preventing pressure ulcers based on the information in the text?(Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has developed a wound on their lower leg. The client has a history of vascular disease. Which of the following factors is most likely contributing to the client's impaired wound healing process?

Correct Answer is C

Explanation

A nurse is selecting a dressing for a patient's pressure ulcer based on wound characteristics. What factors should the nurse consider when making this decision?

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a patient with a pressure ulcer that presents as non-blanchable erythema with intact skin. What clinical manifestation is the nurse likely to observe in this patient?

A nurse is caring for a patient with a stage 3 pressure ulcer. What nursing intervention should the nurse prioritize based on the information provided in the text?

A client with diabetes is receiving care from a nurse. The client is at risk of developing pressure ulcers due to their medical condition. What statement accurately identifies a risk factor for pressure ulcers in this client?

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A nurse is assessing a patient at risk for pressure ulcers. Which interventions are appropriate for preventing pressure ulcers based on the information in the text?(Select all that apply)

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