A nurse is caring for a client with a pressure injury. Which of the following should the nurse recognize as a priority in the plan of care?

Keeping the wound clean and non-infected

Application of a negative pressure wound care device

Client education on wound prevention

Promoting a high carbohydrate, low protein diet

Answer and Explanation

The Correct Answer is A

A. Keeping the wound clean and non-infected: When caring for a client with a pressure injury, the priority in the plan of care is to keep the wound clean and prevent infection. This involves regular wound assessment, proper wound cleaning techniques, application of appropriate dressings, and monitoring for signs of infection such as increased redness, swelling, warmth, or drainage. Preventing infection is crucial for promoting healing and preventing complications.

B. Application of a negative pressure wound care device: While negative pressure wound therapy (NPWT) can be beneficial in promoting wound healing, it may not be the immediate priority unless specifically indicated by the healthcare provider based on the stage and characteristics of the pressure injury. Keeping the wound clean and preventing infection take precedence over NPWT in the initial plan of care.

C. Client education on wound prevention: While client education is important for preventing future pressure injuries, it is not the immediate priority when caring for an existing pressure injury. The focus initially should be on managing the current wound to promote healing and prevent complications.

D. Promoting a high carbohydrate, low protein diet: Nutritional interventions are important in wound healing, but promoting a specific diet is not the immediate priority in the plan of care for a pressure injury. Providing adequate nutrition and addressing any nutritional deficiencies may be part of the overall plan, but it is secondary to keeping the wound clean and preventing infection.

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Correct Answer is D

Explanation

A. A 60-year-old client with gastritis:

Gastritis is inflammation of the stomach lining and typically does not directly increase the risk of skin infections. However, if the gastritis is due to an underlying condition that affects the immune system, such as an autoimmune disorder, the client may have a slightly higher risk of infections, including skin infections, compared to a healthy individual of the same age. Overall, gastritis alone is not a significant risk factor for skin infections compared to the other options.

B. A 20-year-old client with a closed tibia fracture:

A closed tibia fracture refers to a broken shinbone that does not break the skin. While fractures themselves do not necessarily increase the risk of skin infections, they can indirectly contribute to infection risk if there are complications such as open wounds, surgical procedures, or prolonged immobilization. In this case, because the fracture is closed and presumably not complicated by open wounds or surgery, this client is not significantly prone to skin infections compared to the other options.

C. A 55-year-old client taking an ACE inhibitor:

ACE (angiotensin-converting enzyme) inhibitors are medications commonly used to treat conditions like high blood pressure and heart failure. While these medications can cause side effects like a dry cough or skin rash in some individuals, they do not directly increase the risk of skin infections. Unless the client experiences a severe allergic reaction or develops a rash that becomes infected, the use of ACE inhibitors alone is not a major risk factor for skin infections compared to the other options.

D. A 35-year-old client receiving chemotherapy:

Chemotherapy is a treatment for cancer that works by targeting rapidly dividing cells, including cancer cells but also affecting some healthy cells like those in the bone marrow responsible for producing white blood cells. As a result, chemotherapy can significantly weaken the immune system, leading to a higher risk of infections, including skin infections. Patients undergoing chemotherapy are particularly susceptible to bacterial, fungal, and viral infections due to their compromised immune response. Therefore, the 35-year-old client receiving chemotherapy is the most prone to skin infections among the options given due to their weakened immune system.

A. Diarrhea and vomiting for 36 hours B. Chronic obstructive pulmonary disease (COPD) C. Anxiety-induced hyperventilation D. Diabetic ketoacidosis and chronic obstructive pulmonary disease (COPD)

Correct Answer is C

Explanation

A. Diarrhea and vomiting for 36 hours:

Diarrhea and vomiting can lead to metabolic acidosis due to loss of bicarbonate and increased hydrogen ion concentration in the blood. However, the ABG values provided indicate respiratory alkalosis (high pH and low PaCO2), which is not consistent with metabolic acidosis caused by diarrhea and vomiting. Therefore, this choice does not correlate with the ABG values.

B. Chronic obstructive pulmonary disease (COPD):

COPD is a respiratory condition characterized by airflow limitation and increased airway resistance. It can lead to respiratory acidosis due to retention of carbon dioxide (PaCO2 levels would be elevated). The ABG values in the scenario show respiratory alkalosis (low PaCO2), which is the opposite of what would be expected in COPD. Therefore, this choice does not correlate with the ABG values provided.

C. Anxiety-induced hyperventilation:

Anxiety-induced hyperventilation is a common cause of respiratory alkalosis. During hyperventilation, there is excessive elimination of carbon dioxide (PaCO2 levels decrease), leading to an increase in pH (alkalosis). The ABG values in the scenario show a high pH (7.48) and low PaCO2 (28 mm Hg), consistent with respiratory alkalosis seen in hyperventilation due to anxiety.

D. Diabetic ketoacidosis and chronic obstructive pulmonary disease (COPD):

Diabetic ketoacidosis (DKA) is a metabolic condition characterized by hyperglycemia, ketosis, and metabolic acidosis (low pH and low bicarbonate levels). COPD, as mentioned earlier, can lead to respiratory acidosis due to retained carbon dioxide. Neither of these conditions correlates with the ABG values provided, which show respiratory alkalosis (high pH and low PaCO2). Therefore, this choice does not correlate with the ABG values.

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A nurse is caring for a client with a pressure injury. Which of the following should the nurse recognize as a priority in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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