An older adult client with a stage one sacral pressure wound is discharged with instructions for home care. Which information should the practical nurse reinforce with the client?
Apply lotion to sacrum.
Use wet-to-dry dressings daily.
Elevate head of bed 30 degrees.
Change positions every 2 hours.
The Correct Answer is D
A. Apply lotion to sacrum: Applying lotion may help with general skin hydration but does not directly address pressure relief, which is the primary intervention needed to prevent worsening of a stage one pressure injury.
B. Use wet-to-dry dressings daily: Wet-to-dry dressings are used for wounds with necrotic tissue that need debridement. A stage one pressure injury involves intact skin without an open wound, so such dressings are not appropriate.
C. Elevate head of bed 30 degrees: Elevating the head of the bed slightly can reduce aspiration risk but also increases pressure on the sacrum if maintained for long periods. Position changes are more critical to relieve sacral pressure.
D. Change positions every 2 hours: Repositioning every two hours is essential to relieve pressure on the sacrum and promote circulation. This practice helps prevent progression of the pressure injury and is a cornerstone of effective pressure ulcer prevention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Breast pads wet with breast milk from a postpartum client with mastitis: Although mastitis involves infection, breast milk is not classified as a biohazard unless visibly contaminated with blood. Breast pads wet only with milk would typically be discarded in regular waste, not biohazard containers.
B. Straight urinary catheter tray used to collect a urine specimen for culture: The tray may have biological material but is not heavily saturated with blood or other highly infectious fluids. Urine alone, unless grossly bloody, does not typically require disposal in a biohazard container.
C. Urine soiled disposable bed pads for a client with hepatitis C: Even though the client has hepatitis C, urine is generally not considered a high-risk fluid for transmission of bloodborne pathogens unless visibly contaminated with blood. These pads would be disposed of in regular medical waste.
D. Postoperative dressing that is saturated with bright red blood: A dressing heavily saturated with blood must be placed in a biohazard container because blood is classified as a potentially infectious material. Proper disposal prevents exposure to bloodborne pathogens and meets infection control standards.
Correct Answer is ["31"]
Explanation
Total volume to be infused: 250 mL of tube feeding.
To be infused over 8 hours.
Calculate the infusion rate in mL per hour.
Infusion rate (mL/hour) = Total volume (mL) / Total infusion time (hours)
= 250 mL / 8 hours
= 31.25
Round to the nearest whole number: 31.
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