A nurse is planning care for a client who is comatose and has a stage II decubitus ulcer on the coccyx. Which of the following interventions is appropriate to include in the plan of care?
Massage the area to improve circulation
Provide the client with an alternating pressure mattress
Apply a sterile, dry gauze dressing over the client's wound
Place a donut-shaped cushion under the client when in a chair
The Correct Answer is B
Choice A reason: Massaging the area of a pressure ulcer is contraindicated. Massage can damage fragile capillaries and tissues, worsening the ulcer and increasing the risk of further breakdown. It may also cause pain and inflammation. Therefore, this intervention is inappropriate for a stage II ulcer.
Choice B reason: An alternating pressure mattress is an evidence-based intervention that helps redistribute pressure across the body and reduces the risk of further skin breakdown. For a comatose client who cannot reposition themselves, this intervention is especially important. It promotes circulation and prevents worsening of the ulcer, making it the most appropriate choice.
Choice C reason: A sterile, dry gauze dressing is not the recommended treatment for a stage II ulcer. Stage II ulcers involve partial-thickness skin loss and require a moist wound environment to promote healing. Dry gauze can adhere to the wound bed, cause trauma during removal, and delay healing. Moist dressings such as hydrocolloids or foam dressings are preferred.
Choice D reason: Donut-shaped cushions are not recommended because they concentrate pressure around the wound edges, worsening ischemia and tissue damage. They can increase the risk of ulcer progression rather than prevent it. This intervention is inappropriate for pressure ulcer management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Omeprazole is a proton pump inhibitor used to treat gastroesophageal reflux disease (GERD) and peptic ulcer disease. It has no therapeutic role in managing IBS-C. Therefore, this option is incorrect.
Choice B reason: Loperamide is an antidiarrheal medication used to treat diarrhea-predominant IBS (IBS-D). It is not appropriate for constipation-predominant IBS, as it would worsen constipation. This option is incorrect.
Choice C reason: A diet high in fiber is the mainstay of treatment for IBS-C. Fiber increases stool bulk, promotes bowel motility, and helps relieve constipation. This is the correct answer because it directly addresses the underlying problem of constipation in IBS-C.
Choice D reason: Restricting fluid intake would worsen constipation by reducing stool softening and bowel motility. Adequate hydration is essential for managing constipation. Therefore, this option is incorrect.
Correct Answer is B
Explanation
Choice A reason: A gastric residual volume of 250 mL after 2 hours of infusion is not immediately alarming. Clinical guidelines often consider residuals greater than 500 mL or consistently high volumes as concerning for delayed gastric emptying or risk of aspiration. A single residual of 250 mL should be monitored, but it does not require urgent intervention.
Choice B reason: A client lying in a supine position while receiving continuous enteral feedings is at high risk for aspiration. Supine positioning allows gastric contents to reflux into the esophagus and potentially enter the airway, especially in a client with a partial laryngectomy who already has altered airway protection. The immediate intervention is to elevate the head of the bed to at least 30–45 degrees to reduce aspiration risk. This is the most urgent finding because it directly threatens airway safety.
Choice C reason: If the infusion pump is turned off, the client is not receiving nutrition. While this requires correction to ensure adequate caloric intake, it is not immediately life-threatening. The nurse can restart the pump and monitor the client’s nutritional status, but this does not pose an acute danger compared to aspiration risk.
Choice D reason: An undated enteral feeding bag and tubing is a safety concern because it raises the risk of bacterial contamination if the equipment has been in use beyond recommended time frames (usually 24 hours). However, this issue can be corrected by replacing the bag and tubing. It is important but not as urgent as preventing aspiration.
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