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.

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Correct Answer is B

Explanation

A. Partial-thickness skin loss with red tissue in wound bed:
This describes a stage 2 pressure injury, not stage 1.

B. Intact skin with localized erythema:
Stage 1 pressure injuries are characterized by non-blanchable redness (erythema) over intact skin.

C. Full thickness skin loss with visible adipose tissue:
This describes a stage 3 pressure injury.

D. Full thickness skin loss with visible bone:
This describes a stage 4 pressure injury.

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.

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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 collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Correct Answer is B

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 assisting in the care of a client. Exhibits Click to highlight the findings that indicate the interventions were effective. To deselect a finding, click on the finding again. T 38° C (100.4)°F, oral. BP 106/60 mm Hg, supine HR 99/min R 20/min Pulse oximetry 95% on room air

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