A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?

Massage reddened areas during dressing changes.

Apply a heat lamp twice a day.

Cleanse with 0.9% sodium chloride irrigation.

Cleanse with povidone-iodine solution.

Answer and Explanation

The Correct Answer is C

A. Massage reddened areas during dressing changes:
Massaging reddened or compromised skin can worsen tissue damage and increase the risk of further injury.

B. Apply a heat lamp twice a day:
Heat lamps are not recommended and may dry out the wound bed or burn healing tissue.

C. Cleanse with 0.9% sodium chloride irrigation:
Normal saline is gentle and effective for cleaning granulating tissue without causing damage or cytotoxic effects.

D. Cleanse with povidone-iodine solution:
Povidone-iodine is cytotoxic and can impair wound healing, especially to new granulating tissue.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Palpate the client’s pulse at the third intercostal space:
The apical pulse is at the fifth intercostal space, midclavicular line-not the third. The third is not standard for pulse assessment.

B. Ask the client to perform the Valsalva maneuver:
This can be used in arrhythmias like supraventricular tachycardia but is not appropriate for assessment of irregular rhythm.

C. Auscultate the client’s apical pulse:
This is the most accurate way to assess an irregular pulse, especially for one full minute.

D. Check the client’s heart rate for 30 sec:
When a rhythm is irregular, you must assess for a full minute, not 30 seconds.

A. Determine the client's blood pressure 1 min after each position change. B. Assist the client into a standing position. C. Check the blood pressure with the client in a supine position. D. Place the client in a sitting position.

Correct Answer is C

Explanation

A. Determine the client’s BP 1 min after each position change:
This is done after the initial supine BP is obtained. It is not the first action.

B. Assist the client into a standing position:
This comes after checking the BP while the client is supine and sitting. Standing without prior measurements is unsafe.

C. Check the blood pressure with the client in a supine position:
Orthostatic hypotension is diagnosed by comparing BP in different positions; the baseline (supine) is always assessed first.

D. Place the client in a sitting position:
Sitting comes after the supine measurement. It is not the first step.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

Correct Answer is C

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 client's skin integrity?

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device (wound vac) placed over it. Which of the following findings by the nurse, during a dressing change, indicates healing of the wound?

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

A nurse is assisting with the care of a client. Exhibits For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged.

A nurse is collecting data on a client. Which of the following findings increase the client's risk for developing a pressure injury?

A nurse is caring for a client whose surgical abdominal wound has eviscerated. Which of the following actions should the nurse take?

A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make?

A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?