A nurse is caring for a client with a nonhealing arterial lower leg ulcer.
What action by the nurse is best?
Consult with the wound care nurse.
Give pain medication prior to dressing changes.
Maintain sterile technique for dressing changes.
Prepare the client for eventual amputation.
The Correct Answer is A
Choice A rationale
An arterial ulcer is a complex wound resulting from chronic tissue ischemia. A wound care nurse possesses specialized knowledge in advanced wound management techniques, including debridement, moisture balance, and identifying appropriate dressings, which are crucial for promoting healing in these challenging, poorly perfused wounds.
Choice B rationale
While pain management is important for client comfort, it is not the most critical action. The best action is to address the underlying cause of the non-healing wound and implement specialized care that targets the specific challenges of arterial ulcers, such as poor perfusion and a high risk of infection.
Choice C rationale
Maintaining sterile technique is a standard of care to prevent infection, but it is insufficient on its own to heal an arterial ulcer. These wounds require a comprehensive approach that includes improving blood flow, debridement of non-viable tissue, and specialized dressings, which a wound care nurse can best guide.
Choice D rationale
Preparing the client for amputation is a premature and often psychologically damaging action. Amputation is a last resort after all conservative and revascularization options have been exhausted. The primary goal is to heal the ulcer through a concerted effort of specialized wound care and addressing the vascular insufficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Infant skin has greater perfusion compared to adult skin due to a higher ratio of capillaries to surface area. This increased blood flow contributes to the infant's ability to dissipate heat but also makes their skin more susceptible to flushing and temperature changes.
Choice B rationale
While infants have a higher percentage of total body water, their stratum corneum, the outermost layer of skin, is thinner and has a lower lipid content, leading to a higher transepidermal water loss compared to adults. This makes their skin more prone to dryness.
Choice C rationale
Infants have a higher density of eccrine sweat glands, but their thermoregulatory system is immature. They are less efficient at perspiring and have a higher risk of hyperthermia. Their sweat glands are not fully developed or functional, which is different from increased perspiration.
Choice D rationale
Infant skin has a thinner stratum corneum and a higher surface area-to-weight ratio compared to adult skin. This anatomical difference results in a greater percutaneous absorption of topical medications and other substances. This is why care must be taken with the amount of medication applied.
Correct Answer is D
Explanation
Choice A rationale
Wearing comfy sweatpants and house shoes is generally not a barrier to proper foot care. In fact, wearing loose-fitting, comfortable clothing and footwear that does not restrict circulation is beneficial for clients with peripheral vascular disease (PVD). Tight clothing or shoes can impair blood flow, exacerbating the symptoms of PVD and increasing the risk of skin breakdown and ulceration.
Choice B rationale
Receiving energy assistance to keep the house warm is a positive factor for a client with PVD. Cold temperatures cause vasoconstriction, which further reduces blood flow to the extremities. Maintaining a warm environment helps promote vasodilation, improving circulation and reducing the risk of pain, tissue damage, and compromised wound healing.
Choice C rationale
Having plenty of lotion available is a supportive factor for proper foot care. Clients with PVD often have dry, cracked skin due to poor circulation. Using non-alcohol-based lotions can help maintain skin integrity, prevent fissures, and reduce the risk of infection. The daughter’s support facilitates adherence to this aspect of the foot care regimen.
Choice D rationale
Tremors or shaking hands, which indicate a lack of fine motor coordination, pose a significant barrier to proper foot care. This deficit makes it difficult to perform essential tasks such as meticulously inspecting the feet for cuts, blisters, or other injuries, clipping toenails correctly, and applying lotion without causing skin damage. This can lead to missed injuries and delayed treatment.
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