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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Temperature of 39°C (102.2°F):
Fever typically causes an increase in heart rate, not bradycardia.
B. Hypoglycemia:
Hypoglycemia is more commonly associated with tachycardia, sweating, and tremors, not bradycardia.
C. Report of dizziness:
Bradycardia (HR <60/min) can lead to decreased cardiac output and cerebral perfusion, causing dizziness.
D. History of cigarette smoking:
Smoking is associated with cardiovascular disease but not specifically bradycardia.
Correct Answer is C
Explanation
A. Decrease the temperature in the client’s room:
This would worsen hypothermia. The room should be warm.
B. Place a cooling fan near the client:
Cooling is used for fevers, not hypothermia.
C. Place a warming blanket over the client:
This is a first-line intervention for mild hypothermia. It helps raise the core temperature.
D. Request a prescription for an antipyretic medication:
Antipyretics are used to reduce fever, not to treat hypothermia.
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