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 A
Explanation
A. Remove excess clothing from the client:
This is a non-pharmacological cooling measure that promotes heat dissipation and lowers core body temperature.
B. Restrict the client’s fluid intake:
Clients with fever are at risk for dehydration, so fluids should be encouraged, not restricted.
C. Place a warming blanket over the client:
A warming blanket will raise body temperature further, which is contraindicated in a febrile client.
D. Increase the temperature in the client’s room:
The room should be kept at a comfortable and cool temperature to help reduce fever.
Correct Answer is D
Explanation
A. Decreased serum calcium:
Low calcium affects bones and muscle contraction but is not directly related to pressure injury development.
B. Increased muscle mass:
Increased muscle mass helps protect against pressure injury by providing padding and blood flow.
C. Decreased circulation:
Poor circulation leads to inadequate oxygen and nutrient delivery to tissues, increasing the risk of pressure injury, especially in immobile clients.
D. Increased collagen:
Collagen is essential for skin integrity and wound healing. Increased collagen would protect, not harm, tissue.
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