A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?
Apply a heat lamp twice a day.
Reposition the client at least every 2 hours.
Massage reddened areas with dressing changes.
Clean the wound with hydrogen peroxide solution.
The Correct Answer is B
Choice A reason:
Applying a heat lamp twice a day is not recommended for treating stage 3 pressure ulcers. Heat lamps can cause burns and further damage to the already compromised skin. The primary goal in treating pressure ulcers is to reduce pressure, keep the area clean, and promote healing. Heat lamps do not contribute to these goals and can potentially worsen the condition.
Choice B reason:
Repositioning the client at least every 2 hours is a crucial intervention for managing stage 3 pressure ulcers. Frequent repositioning helps to alleviate pressure on the affected area, improving blood flow and preventing further tissue damage. This practice is essential in preventing the progression of pressure ulcers and promoting healing. It is one of the most effective strategies in pressure ulcer management.
Choice C reason:
Massaging reddened areas with dressing changes is not advisable. Massaging can cause additional trauma to the skin and underlying tissues, potentially worsening the ulcer. Instead, gentle handling and appropriate wound care techniques should be used to avoid further damage. Massaging can also disrupt the healing process and increase the risk of infection.
Choice D reason:
Cleaning the wound with hydrogen peroxide solution is not recommended for stage 3 pressure ulcers. Hydrogen peroxide can damage healthy tissue and delay the healing process. It is better to use saline or other wound cleaning solutions that are gentle and effective in removing debris without harming the tissue. Proper wound cleaning is essential to prevent infection and promote healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Transporting a school-age client who is in traction to another department is unsafe for a volunteer. Traction involves the use of weights and pulleys to align or immobilize a part of the body, typically after a fracture. This requires careful handling and monitoring to ensure the traction remains effective and does not cause additional injury. Only trained healthcare professionals should manage and transport clients in traction to prevent complications.
Choice B reason: Reading a book to a preschool client who has AIDS is a safe and appropriate assignment for a volunteer. AIDS (Acquired Immunodeficiency Syndrome) is not transmitted through casual contact such as reading a book together. Volunteers can provide emotional support and companionship to children with AIDS without risk of transmission.
Choice C reason: Playing a computer video game with an adolescent who has sickle cell disease is also a safe and suitable activity for a volunteer. Sickle cell disease is a genetic disorder that affects the shape of red blood cells, leading to various complications. However, it is not contagious, and engaging in recreational activities can help improve the adolescent’s quality of life and provide a sense of normalcy.
Choice D reason: Rocking an infant who was admitted for croup is a safe task for a volunteer. Croup is a respiratory condition characterized by a barking cough, often caused by a viral infection. While it can be contagious, the risk of transmission can be minimized with proper hygiene practices. Volunteers can provide comfort and soothing to infants with croup under the supervision of healthcare staff.
Correct Answer is A
Explanation
Choice A reason:
Swelling in the face, particularly around the eyes, is a common symptom of nephrotic syndrome. This condition causes the kidneys to leak large amounts of protein into the urine, leading to a decrease in blood protein levels. This imbalance causes fluid to accumulate in tissues, resulting in swelling (edema), especially in areas like the face and ankles.
Choice B reason:
Losing protein in the urine, known as proteinuria, is a hallmark of nephrotic syndrome. The condition damages the glomeruli in the kidneys, which are responsible for filtering waste and retaining essential proteins. When these filters are damaged, proteins like albumin leak into the urine, leading to significant protein loss.
Choice C reason:
Increasing sodium intake is not recommended for clients with nephrotic syndrome. In fact, a low-sodium diet is often advised to help manage symptoms such as swelling and high blood pressure. Excess sodium can exacerbate fluid retention and worsen edema.
Choice D reason:
A kidney biopsy is a common diagnostic procedure for nephrotic syndrome. It involves taking a small sample of kidney tissue to examine under a microscope. This helps determine the underlying cause of the syndrome and guides treatment decisions.
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