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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["10"]

Explanation

Step 1: Determine the concentration of the suspension. 250 mg ÷ 5 mL = 50 mg/mL

Result: 50 mg/mL

Step 2: Calculate the amount of mL needed for a 500 mg dose. 500 mg ÷ 50 mg/mL = 10 mL

Result: 10 mL

Final Answer: The nurse should administer 10 mL per dose.

A. Treat clients with an antitoxin. B. Administer antibiotic therapy. C. Initiate client decontamination. D. Place the clients in isolation.

Correct Answer is B

Explanation

Choice A reason:

The statement “Treat clients with an antitoxin” is not the primary initial action for anthrax exposure. Antitoxins are used in cases of severe anthrax infection, particularly inhalational anthrax, to neutralize the toxins produced by Bacillus anthracis. However, the first line of treatment for suspected anthrax exposure is antibiotic therapy to eliminate the bacteria.

Choice B reason:

The statement “Administer antibiotic therapy” is correct. The primary treatment for anthrax exposure is the prompt administration of antibiotics. Ciprofloxacin and doxycycline are commonly used antibiotics for treating anthrax. Early antibiotic treatment is crucial to prevent the progression of the disease and reduce the risk of severe complications.

Choice C reason:

The statement “Initiate client decontamination” is not typically necessary for anthrax exposure. Anthrax spores are not easily spread from person to person, and decontamination is generally not required unless there is a significant risk of environmental contamination. The focus should be on administering antibiotics and monitoring the clients for symptoms.

Choice D reason:

The statement “Place the clients in isolation” is incorrect. Anthrax is not contagious and does not spread from person to person. Therefore, isolation is not required for individuals exposed to anthrax. The priority is to provide appropriate medical treatment and monitor for signs of infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["10"]

Explanation

A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work. Which of the following is the appropriate action for the nurse to take?

Correct Answer is B

Explanation

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