A nurse is caring for a client who has a stage II pressure ulcer. Which of the following products should the nurse use to treat the ulcer?

Granulex

Hydrocolloid

Proteolytic enzyme

Cortisone cream

Answer and Explanation

The Correct Answer is B

A.   Granulex is a topical medication used for wound care, but it may not be the first choice for a stage II pressure ulcer.
B.   Hydrocolloid dressings are appropriate for stage II pressure ulcers, providing a moist environment to support healing and protecting the wound from contamination.
C.   Proteolytic enzymes are used for debridement of necrotic tissue and may not be the primary choice for a stage II pressure ulcer.

D.   Cortisone cream is a topical steroid that may be used for certain skin conditions but is not typically the first-line treatment for pressure ulcers.

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Correct Answer is C

Explanation

A. 2+ pitting edema is not a contraindication to cold application; in fact, cold application can help reduce edema.
B. A 7.5 cm (3 in) diameter bruise on the ankle is not a contraindication to cold application; cold can help reduce swelling and alleviate pain.
C. Capillary refill of 4 seconds suggests compromised blood flow, and cold application may further impair circulation. It is a contraindication.
D. Warts on the affected ankle are not a contraindication to cold application.

A. Don sterile gloves prior to the procedure. B. Lubricate 1 inch of the tip of the rectal tube prior to insertion. C. Place the client into a left Sims' position. D. Raise the enema bag if the client experiences cramping.

Correct Answer is C

Explanation

A. Sterile gloves are not necessary for a tap water enema; clean, non-sterile gloves are sufficient.

B. Lubricating the tip of the rectal tube is appropriate to ease insertion and enhance client comfort.
C. Placing the client into a left Sims' position facilitates optimal administration of a tap water enema.
D. Lowering, not raising, the enema bag will allow for a slower flow and may reduce cramping.

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A nurse is caring for a client who has a stage II pressure ulcer. Which of the following products should the nurse use to treat the ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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