A stage 3 pressure ulcer is noted on a patient's coccyx. What is the primary goal of the nursing care plan for this patient?
Ensure complete bed rest.
Prevent further tissue breakdown.
Encourage high protein diet.
Increase patient's fluid intake.
The Correct Answer is B
A. Ensure complete bed rest: Complete bed rest is contraindicated because it increases the risk of new pressure injuries and complications like pneumonia and deep vein thrombosis (DVT). The patient must be turned and mobilized as tolerated.
B. Prevent further tissue breakdown: The primary goal in the care plan for an existing pressure injury (Stage 3 or any other stage) is to prevent the injury from worsening (e.g., advancing to Stage 4) and to prevent the formation of new pressure injuries at other sites. This is achieved through aggressive pressure relief and proper moisture management.
C. Encourage high protein diet: This is an essential component of the care plan, as protein is necessary for wound repair, but it is a supportive intervention, not the primary goal itself. The goal is the clinical outcome (prevention/healing).
D. Increase patient's fluid intake: This is an important intervention for perfusion and tissue hydration, but like the high-protein diet, it is a supportive action rather than the primary goal of the nursing care plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply alcohol-based products to dry the skin: Alcohol is extremely drying and irritating; it strips the skin of its natural oils, leading to further skin damage.
B. Use moisture-wicking linens and change them frequently: Moisture-wicking materials (linens and clothing) draw moisture away from the skin, and frequent changes prevent the skin from remaining in prolonged contact with sweat, thereby protecting the skin barrier from maceration.
C. Apply talcum powder to absorb moisture: Talcum powder can clump when mixed with sweat, creating an abrasive paste that increases friction and irritation, leading to skin breakdown.
D. Decrease fluid intake to reduce sweating: Decreasing fluid intake can lead to dehydration, which is detrimental to overall health and wound healing, and is an inappropriate and dangerous method for managing diaphoresis.
Correct Answer is D
Explanation
A. Presence of slough or eschar: Both Stage 2 and Stage 3 injuries may eventually develop some slough if they deteriorate or if they are mismanaged. However, slough and eschar are defining characteristics of an unstageable injury if they obscure the wound base. A clean Stage 2 injury will not have slough or eschar.
B. Nonblanchable erythema: Nonblanchable erythema is the defining characteristic of a Stage 1 pressure injury, which involves intact skin. Stage 2 and Stage 3 both involve skin loss.
C. Exposed muscle or bone: Exposed muscle or bone indicates a Stage 4 pressure injury.
D. Partial-thickness skin loss: A Stage 2 pressure injury is defined by partial-thickness loss of the dermis. A Stage 3 pressure injury is defined by full-thickness tissue loss involving the subcutaneous fat. This difference in thickness is the key distinction.
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