A nurse is contributing to the plan of care for a client who has a superficial skin tear with no exudate. Which of the following dressings should the nurse recommend to cover the wound?

Hydrofiber dressing

Transparent-film dressing

Alginate dressing

Foam dressing

Answer and Explanation

The Correct Answer is B

A. Hydrofiber dressing:
Hydrofiber dressings are designed for moderate to heavy exudate, not dry or non-exudative wounds.

B. Transparent-film dressing:
Transparent-film dressings are ideal for superficial, non-draining wounds like skin tears. They protect the area while allowing for oxygen exchange and visualization of the wound.

C. Alginate dressing:
Alginate dressings are highly absorbent and used for moderate to heavy exudating wounds, not for dry superficial tears.

D. Foam dressing:
Foam dressings are best for wounds with exudate. They are thicker and may not adhere well to superficial skin tears without drainage.

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Correct Answer is C

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.

A. Elevate the client's arm above the level of the heart. B. Align the artery indicator on the blood pressure cuff with the client's brachial artery. C. Place the blood pressure cuff 5 cm (2 in) above the client's antecubital space. D. Select a cuff that covers 50% of the client's upper arm.

Correct Answer is B

Explanation

A. Elevate the client’s arm above the level of the heart:
This may falsely lower the reading. The arm should be at heart level.

B. Align the artery indicator on the BP cuff with the client’s brachial artery:
Correct alignment ensures accurate readings. Most cuffs have an arrow or line that must align with the brachial artery.

C. Place the BP cuff 5 cm (2 in) above the client’s antecubital space:
The cuff should be placed about 2.5 cm (1 inch) above the antecubital space-not 5 cm.

D. Select a cuff that covers 50% of the client’s upper arm:
The correct cuff should cover at least 80% of the arm’s circumference, not 50%, for accurate readings.

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A nurse is contributing to the plan of care for a client who has a superficial skin tear with no exudate. Which of the following dressings should the nurse recommend to cover the wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?

Correct Answer is C

Explanation

A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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