A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Alginate

Gauze

Transparent

Hydrocolloid

Answer and Explanation

The Correct Answer is D

A. Alginate: Alginate dressings are highly absorbent dressings derived from seaweed and are typically used for wounds with moderate to heavy exudate. They are most appropriate for deeper wounds such as stage 3 or stage 4 pressure injuries, tunneling wounds, or bleeding wounds.

B. Gauze: Gauze dressings are considered a basic wound covering and are often used for packing deeper wounds or covering secondary dressings. They do not maintain a moist wound environment effectively and can adhere to the wound bed, potentially causing trauma to newly forming tissue during removal.

C. Transparent: Transparent film dressings are thin, adhesive coverings that allow visualization of the wound and are primarily used for superficial wounds with minimal drainage, such as stage 1 pressure injuries or areas at risk for breakdown. Stage 2 pressure injuries produce exudate, transparent films may not provide sufficient absorption or protection.

D. Hydrocolloid: Hydrocolloid dressings contain gel-forming agents that interact with wound exudate to create a moist healing environment. This environment promotes epithelial cell migration, supports autolytic debridement, and protects the wound from external contamination. Hydrocolloids are commonly recommended for stage 2 pressure injuries because they maintain moisture balance while providing cushioning and protection to the fragile tissue.

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Correct Answer is D

Explanation

A. "Is your pain constant or intermittent?": This question addresses the temporal pattern of the pain, which helps determine duration and frequency, but it does not describe the specific characteristics or quality of the pain itself. Temporal factors are important for overall assessment but are not the primary focus when evaluating pain quality.

B. "What would you rate your pain on a scale of 0 to 10?": This question evaluates pain intensity rather than quality. While numerical rating scales are useful for quantifying pain severity and monitoring response to interventions, they do not provide descriptive information about the nature or type of pain the client is experiencing.

C. "Does the pain radiate?": Asking about radiation helps assess the location and potential referral pattern of the pain, which is important for identifying the source or underlying pathology. However, it does not directly assess the sensory characteristics that define the quality of the pain, such as whether it is sharp, burning, or throbbing.

D. "Is your pain sharp or dull?": This question directly addresses the quality of pain, describing its sensory characteristics. Understanding whether the pain is sharp, dull, stabbing, or aching helps guide clinical assessment, identify the underlying cause, and tailor interventions appropriately. Evaluating pain quality is essential for an accurate and comprehensive pain assessment.

A. Place a name tag on the body. B. Obtain the pronouncement of death from the provider. C. Remove tubes and indwelling lines. D. Wash the client's body. E. Ask the client's family members if they would like to view the body.

Correct Answer is A,B,C,D,E

Explanation

A. Place a name tag on the body: This step is performed last to ensure proper identification before the body is transferred to the morgue or funeral services. Tagging the body too early could lead to misidentification if other steps, such as cleaning or repositioning, are not yet completed.

B. Obtain the pronouncement of death from the provider: The first step after a client dies is to have the death officially pronounced by a licensed healthcare provider. This legal and clinical confirmation is necessary before any postmortem care, removal of tubes, or family viewing can take place.

C. Remove tubes and indwelling lines: Once death has been pronounced, the nurse can safely remove medical devices such as IV lines, catheters, and drains. This prepares the body for cleaning and ensures dignity while preventing potential leakage or contamination.

D. Wash the client's body: Cleaning the body is important for infection control, hygiene, and maintaining respect and dignity. Washing the body also provides a more comfortable and presentable appearance for family viewing.

E. Ask the client's family members if they would like to view the body: After the body has been cleaned and prepared, the family can be offered the opportunity to view or spend time with their loved one. This step provides emotional closure and respects family preferences while maintaining the client’s dignity.

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A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

Correct Answer is D

Explanation

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,D,E

Explanation

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