A nurse is developing a plan of care for a client who has a stage pressure ulcer. Which of the following interventions should the nurse include in the plan?

Reposition the client at least every 2 hours.

Clean the wound with hydrogen peroxide solution.

Massage reddened areas with dressing changes.

Apply a heat lamp twice a day.

Answer and Explanation

The Correct Answer is A

A: Repositioning the client at least every 2 hours is crucial for preventing further pressure ulcers and promoting healing. Regular repositioning helps to relieve pressure on vulnerable areas, improve circulation, and prevent skin breakdown.

B: Cleaning the wound with hydrogen peroxide solution is not recommended. Hydrogen peroxide can damage healthy tissue and delay wound healing. Saline or a gentle wound cleanser should be used instead.

C: Massaging reddened areas with dressing changes is not advisable. Massaging can cause further damage to already compromised skin and tissues. Gentle handling and avoiding pressure on these areas are more appropriate.

D: Applying a heat lamp twice a day is not a standard intervention for pressure ulcers. Heat lamps can cause burns and further damage to the skin. Maintaining a moist wound environment and using appropriate dressings are better practices.

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Correct Answer is C

Explanation

A: Having a small snack and taking a bath before bed can promote relaxation and improve sleep quality.

B: Going to bed and getting up at the same time each day helps regulate the body’s internal clock and promotes better sleep.

C: Watching television until falling asleep can interfere with sleep quality. The light from screens can disrupt the production of melatonin, a hormone that regulates sleep.

D: Avoiding naps throughout the day can help maintain a consistent sleep schedule and improve nighttime sleep quality.

A. “I can drink cranberry juice each day.” B. “I will need to wipe my perineal area from back to front after urination.” C. “I will need to empty my bladder regularly and completely.” D. “I need to drink 8 cups of liquid each day.”

Correct Answer is B

Explanation

A: Drinking cranberry juice each day can help prevent UTIs. Cranberry juice contains compounds that may prevent bacteria from adhering to the urinary tract walls, reducing the risk of infection.

B: Wiping the perineal area from back to front after urination is incorrect and increases the risk of introducing bacteria from the anal area to the urethra, leading to UTIs. The correct method is to wipe from front to back to minimize this risk.

C: Emptying the bladder regularly and completely is an important measure to prevent UTIs. It helps flush out bacteria from the urinary tract and reduces the risk of infection.

D: Drinking 8 cups of liquid each day is recommended to maintain adequate hydration and promote regular urination, which helps prevent UTIs by flushing out bacteria.

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A nurse is developing a plan of care for a client who has a stage pressure ulcer. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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