A nurse is assisting with developing a plan of care for a client.
Exhibit 1
Nurses' Notes
2 days ago:
Client admitted to telemetry unit for uncontrolled atrial fibrillation. Admission skin assessment, area of intact, blanchable skin on client's coccyx.
Today, 0900:
Wound on client's coccyx no longer covered with intact skin. Wound involves full-thickness skin loss, shallow depth with no tunneling. New granulation noted. Minimal amount of exudate noted. Client reports wound pain as 5 on a scale of 0 to 10 and is unable to find a comfortable position.
Complete the following sentence by using the lists of options.
The nurse understands that which of the following dressing should be added to the plan of care Select...
hydrocolloid
dry gauze
hydrogel
alginate
transparent
Correct Answer : A
A. A hydrocolloid dressing is a type of dressing that is used for wounds with minimal exudate, such as the wound on the client's coccyx described in the scenario. It provides a moist environment for wound healing and can help with pain relief. This type of dressing is suitable for wounds with granulation tissue and can help protect the wound from further damage while promoting healing.
B. A dry gauze is not appropriate for this type of wound as it does not provide the necessary moist environment for healing and may adhere to the wound, causing damage upon removal.
C. A hydrogel dressing is typically used for wounds with moderate to heavy exudate.
D. An alginate dressing is typically used for wounds with moderate to heavy exudate. These dressings may not be suitable for the described wound with minimal exudate.
E. A transparent dressing may not be suitable for a wound with granulation tissue and moderate exudate, as it may not provide adequate protection and moisture to the wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
A. Despite the client reporting thirst and frequent urination, the client's urine specific gravity of 1.010 is within the normal range (1.005 to 1.030). The above symptoms could be associated with the hyperglycemia.
B. There is no indication of a pneumothorax in the nurse's notes or diagnostic results.
C. The casual glucose level of 300 mg/dL is significantly above the normal range (less than 200 mg/dL), indicating hyperglycemia.
D. The client’s WBC level is elevated, 11,500/mm3 (5,000 to 10,000/mm3) thus indicating an infection.
Correct Answer is ["A","B","C","D"]
Explanation
A. The client has hypertension and high sodium levels, indicating fluid retention, so a diuretic may be prescribed to help manage these conditions.
B. The client reports difficulty sleeping without drinking several beers a night, indicating a potential alcohol problem. Limiting alcohol intake is a common recommendation for clients with this issue.
C. The client has elevated LDL cholesterol, indicating high-fat intake, so limiting fat intake can help manage this.
D. The client has elevated sodium levels, so reducing sodium intake can help manage this.
E. There is no indication for an antibiotic prescription based on the client's symptoms and lab results.
F. There is no indication of high potassium levels, so limiting foods high in potassium is not necessary.
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