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 A

Explanation

A: The passage of flatus is a clear indication that intestinal function is returning. It shows that the gastrointestinal tract is beginning to move gas through the intestines, which is a positive sign of recovery after abdominal surgery.

B: A request for a cup of tea and some toast indicates that the client is feeling better and has an appetite, but it does not specifically indicate the return of intestinal function.

C: Hypoactive bowel sounds in two quadrants suggest reduced intestinal activity, which is not a sign of returning intestinal function. Normal bowel sounds should be present in all quadrants.

D: Abdominal distention can indicate a buildup of gas or fluid in the intestines, which is not a sign of returning intestinal function. It may suggest an obstruction or other complications.

A. Place the client supine with knees bent. B. Raise the head of the client’s bed 15 to 20 degrees. C. Assess the client for manifestations of shock. D. Cover the area with a sterile dressing moistened with 0.9% sodium chloride irrigation.

Correct Answer is D

Explanation

A: Placing the client supine with knees bent can help reduce strain on the abdominal area but is not the immediate first action.

B: Raising the head of the client’s bed 15 to 20 degrees is not the priority action in this situation.

C: Assessing the client for manifestations of shock is important but should follow the immediate action of protecting the eviscerated wound.

D: Covering the area with a sterile dressing moistened with 0.9% sodium chloride irrigation is the correct first action. This helps protect the exposed organs and tissues from contamination and keeps them moist until surgical intervention can be performed.

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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

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that intestinal function is returning?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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