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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Correct Answer is C

Explanation

Choice A reason:

The purpose of a Jackson-Pratt (JP) drain is not to eliminate the need for wound irrigations. Wound irrigation is a critical step in wound care that helps remove debris, reduce bacterial load, and create an optimal environment for healing. The JP drain helps manage fluid accumulation but does not replace the need for proper wound irrigation.

Choice B reason:

While a JP drain can help manage bleeding by providing a pathway for blood to exit the wound, its primary purpose is not to limit bleeding. Instead, it is designed to prevent the accumulation of fluids such as blood, serous fluid, and other exudates that can impede healing and increase the risk of infection. Managing bleeding typically involves other interventions such as surgical hemostasis techniques.

Choice C reason:

The primary purpose of a Jackson-Pratt drain is to prevent fluid from accumulating in the wound. After surgery, wounds can produce various fluids, including blood and lymphatic fluid. Accumulation of these fluids can delay healing and increase the risk of infection. The JP drain uses gentle suction to draw these fluids away from the wound site, promoting faster healing and reducing the risk of complications.

Choice D reason:

A JP drain is not typically used to provide a means for medication administration. Medications are usually administered through other routes such as oral, intravenous, or through specialized catheters designed for medication delivery. The JP drain is specifically designed for fluid drainage and not for delivering medications.

A. Activate the patch 30 minutes after application. B. Take this medication daily to prevent headaches. C. Use contraception while taking this medication. D. You can bathe with the patch in place.

Correct Answer is C

Explanation

Choice A reason: Activate the patch 30 minutes after application

This statement is incorrect. The transdermal sumatriptan patch should be activated immediately after application, not 30 minutes later. The patch uses a mild electrical current to deliver the medication through the skin, and delaying activation would reduce its effectiveness.

Choice B reason: Take this medication daily to prevent headaches

This statement is also incorrect. Sumatriptan is used to treat acute migraine attacks and is not intended for daily use to prevent headaches. It should be used only when a migraine begins. Daily use could lead to medication overuse headaches and other side effects.

Choice C reason: Use contraception while taking this medication

This statement is correct. Women of childbearing age should use contraception while taking sumatriptan because its safety during pregnancy has not been established. It is important to avoid potential risks to the fetus.

Choice D reason: You can bathe with the patch in place

This statement is correct. The transdermal sumatriptan patch is designed to stay in place during bathing, showering, or swimming. However, it is not the most critical piece of information compared to the need for contraception.

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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?

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