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. Require family members and visitors to wear a mask and gown when visiting the client: Masks and gowns are needed in healthcare settings to prevent cross-contamination, but at home, strict use of personal protective equipment (PPE) is not typically necessary for a draining wound unless there is high-risk exposure. Basic hygiene is usually sufficient.
B. Have the client stay in a room separate from the family with the door closed: Isolation at home is generally not necessary unless the infection is highly contagious through casual contact. Emphasis should instead be placed on good wound care and proper hygiene practices.
C. Use paper plates and disposable utensils for the client's meals and snacks: There is no need to use disposable eating utensils. Normal dishwashing practices are adequate to prevent the spread of infection in a home environment, as long as proper cleaning is maintained.
D. Place soiled dressings in a plastic bag that can be tightly secured for disposal: Proper disposal of contaminated dressings in a sealed plastic bag prevents leakage and minimizes exposure to infectious materials. This practice protects household members from accidental contact with wound drainage.
Correct Answer is C
Explanation
A. Use a gait belt during ambulation: A gait belt helps with safe ambulation but does not directly prevent footdrop, which results from muscle weakness or nerve damage when the foot remains in a pointed downward position for too long.
B. Elevate the feet while in bed: Elevating the feet may help with circulation and swelling, but it does not address the muscle weakness or nerve inactivity that can cause footdrop.
C. Begin range of motion exercises: Range of motion exercises maintain joint flexibility and muscle strength, which are essential to prevent footdrop. Moving the ankle and foot helps avoid stiffness and maintains dorsiflexion function.
D. Apply compression stockings: Compression stockings prevent blood clots and control swelling but do not prevent the muscular and neurological complications that lead to footdrop.
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