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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Bake or grill the meat rather than frying it."
This statement is more related to reducing fat intake rather than managing sodium levels. While reducing fried foods can be beneficial for overall health, it doesn't directly address the issue of sodium intake, which is crucial in managing hypernatremia.
B. “Check your radial pulse twice a day.”
Checking the radial pulse is a method used to monitor heart rate and rhythm. It is not directly related to managing sodium levels or hypernatremia. Although monitoring vital signs is important in general health care, it is not specific to addressing mild hypernatremia.
C. "Read food labels to determine sodium content."
This statement is the correct choice. Managing sodium intake is a key component in managing hypernatremia. Reading food labels helps patients identify high-sodium foods and make choices that are lower in sodium content, which can be crucial in preventing or managing mild hypernatremia.
D. “Weigh yourself every morning and every night."
While regular weight monitoring can be important for certain health conditions, it is not directly related to managing mild hypernatremia. Weight changes may occur with fluid retention or loss, but monitoring sodium intake and hydration status is more directly relevant to managing hypernatremia.
Correct Answer is A
Explanation
A. Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
This response is the best choice because it educates the client about the potential for deeper tissue damage associated with electrical burns. It acknowledges that while the burn on the skin may appear small, the damage underneath could be more extensive, affecting muscles, nerves, and blood vessels.
B. Electrical burns commonly cause reddened/purplish skin without blistering.
This statement is not the best response because it focuses solely on the appearance of the skin without addressing the potential for deeper tissue damage. While it is true that electrical burns can present with reddened or purplish skin without blistering, this response does not provide comprehensive information about the nature and severity of electrical burns.
C. Electrical burns typically are minor.
This response is incorrect because it downplays the seriousness of electrical burns. While some electrical burns may indeed be minor, others can cause significant tissue damage and complications. It's important for the nurse to educate the client about the range of severity that electrical burns can present.
D. Electrical burns usually cause much more skin damage than what can be seen on your skin.
This statement is partially accurate but does not provide as much information as choice A. While it acknowledges that electrical burns can cause more damage than what is visible on the skin's surface, it doesn't emphasize the potential for deeper tissue damage as effectively as choice A does.
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