A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Alginate dressing

Hydrogel dressing

Transparent dressing

Wet-to-dry gauze dressing

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Alginate dressings are typically used for wounds with moderate to heavy exudate because they are highly absorbent. Stage I pressure ulcers do not usually produce exudate, making alginate dressings unnecessary and inappropriate for this type of wound.

Choice B Reason:

Hydrogel dressings are designed to provide moisture to dry wounds and are more suitable for wounds with minimal to no exudate. While they can be used for stage I pressure ulcers, they are not the most common choice as these ulcers do not typically require additional moisture.

Choice C Reason:

Transparent dressings are ideal for stage I pressure ulcers because they protect the skin from friction and shear while allowing for continuous observation of the wound. These dressings maintain a moist environment, which is beneficial for healing, and are easy to apply and remove without causing additional trauma to the skin.

Choice D Reason:

Wet-to-dry gauze dressings are generally used for debridement of necrotic tissue in more advanced wounds. They are not suitable for stage I pressure ulcers, which do not have necrotic tissue and do not require debridement.

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Correct Answer is A

Explanation

Choice A reason: Positioning the collection device below the level of the chest is crucial to ensure proper drainage of air or fluid from the pleural space. This positioning uses gravity to facilitate drainage and prevent backflow into the pleural cavity, which could lead to complications such as pneumothorax or pleural effusion. The collection device should always be kept below the chest level to maintain effective drainage.

Choice B reason: Clamping the chest tube is generally not recommended unless specifically ordered by a physician or during certain procedures. Clamping can lead to a buildup of air or fluid in the pleural space, increasing the risk of tension pneumothorax. It is essential to keep the chest tube unclamped to allow continuous drainage and prevent complications.

Choice C reason: Applying an occlusive dressing over the chest tube site is necessary to prevent air from entering the pleural space and to secure the tube. However, this is not the primary action related to the positioning of the collection device. The occlusive dressing helps maintain the integrity of the chest tube insertion site and prevents infection.

Choice D reason: Emptying the chest tube collection chamber every shift is not a standard practice. The collection chamber should be monitored and emptied as needed based on the volume of drainage and the specific protocols of the healthcare facility. Regular monitoring is essential, but unnecessary emptying can disrupt the closed system and increase the risk of infection.

A. Encourage coughing and deep breathing. B. Elevate the client to a high Fowler’s position. C. Administer prescribed analgesic medication. D. Administer oxygen at 2 L/min.

Correct Answer is D

Explanation

Choice A reason: Encouraging coughing and deep breathing is important for postoperative care to prevent complications such as atelectasis and pneumonia. However, with an oxygen saturation of 85%, the immediate priority is to address the client’s hypoxemia. Once oxygen levels are stabilized, coughing and deep breathing exercises can be encouraged.

Choice B reason: Elevating the client to a high Fowler’s position can help improve lung expansion and ease breathing. While this is a beneficial intervention, it is not the first priority when the client’s oxygen saturation is critically low. Administering oxygen should be the initial step to quickly improve oxygenation.

Choice C reason: Administering prescribed analgesic medication is essential for managing the client’s pain, which can also help improve breathing patterns. However, pain management should follow the immediate correction of hypoxemia. Ensuring adequate oxygenation takes precedence over pain relief in this scenario.

Choice D reason: Administering oxygen at 2 L/min is the first action the nurse should take. With an oxygen saturation of 85%, the client is experiencing significant hypoxemia, which needs to be corrected promptly to prevent further complications. Oxygen therapy will help increase the oxygen levels in the blood and improve the client’s overall condition.

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A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Nursing Test Bank

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