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: Debriding the wound is the next step for a black (necrotic) pressure ulcer. Removing the dead tissue is essential to promote healing and prevent infection.

B: Managing drainage is important for wound care but is not the immediate next step for a necrotic ulcer.

C: Documenting the wound is necessary but does not address the need for debridement.

D: Monitoring the wound is important, but active intervention (debridement) is required for a necrotic ulcer to promote healing.

A. Obtain a chest x-ray. B. Raise the head of the bed. C. Administer prescribed analgesic. D. Administer oxygen at 2 L/min.

Correct Answer is B

Explanation

A: Obtaining a chest x-ray is important for diagnosing potential complications but is not the immediate first action to improve oxygen saturation.

B: Raising the head of the bed helps improve lung expansion and oxygenation. It is a quick and effective first step to increase oxygen saturation.

C: Administering a prescribed analgesic can help with pain management but does not directly address the low oxygen saturation.

D: Administering oxygen at 2 L/min is important but should follow the initial step of raising the head of the bed to optimize breathing.

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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?

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