A nurse is caring for a client who has a pressure ulcer on the sacrum. Which intervention should the nurse perform first?

Apply a hydrocolloid dressing to the wound. Assess the wound for signs of infection.

Assess the wound for signs of infection.

Cleanse the wound with normal saline solution.

Reposition the client to relieve pressure on the wound.

Answer and Explanation

The Correct Answer is D

Correct answer: D) Reposition the client to relieve pressure on the wound.

Rationale: The nurse should follow the ABCDE priority-setting framework when caring for a client with a pressure ulcer. The first priority is to address airway, breathing, and circulation (ABC) issues, which include relieving pressure on the wound to prevent further tissue damage and promote blood flow to the area. The other interventions are also important, but they are not the first priority.

Incorrect options:

A) Apply a hydrocolloid dressing to the wound. - This is an appropriate intervention, as hydrocolloid dressings provide a moist environment that promotes wound healing and prevents bacterial contamination. However, this is not the first priority, as it does not address ABC issues.

B) Assess the wound for signs of infection. - This is an appropriate intervention, as assessing the wound for signs of infection, such as redness, swelling, warmth, drainage, odor, or increased pain, is essential to monitor the wound healing process and identify any complications. However, this is not the first priority, as it does not address ABC issues.

C) Cleanse the wound with normal saline solution. - This is an appropriate intervention, as cleansing the wound with normal saline solution helps to remove debris and bacteria from the wound and prevent infection. However, this is not the first priority, as it does not address ABC issues.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Correct answer: D) Consult with the provider about surgical debridement.

Rationale: The nurse should consult with the provider about surgical debridement for a wound that has a black, dry, and hard eschar covering most of its surface. This type of eschar indicates necrotic tissue that impairs wound healing and increases the risk of infection. Surgical debridement is the most effective method of removing large amounts of necrotic tissue from a wound.

Incorrect options:

A) Debride the wound using wet-to-dry dressings. - This is not an appropriate intervention, as wet-to-dry dressings are not recommended for wounds with dry eschar, as they can cause trauma and bleeding to healthy tissue. Wet-to-dry dressings are used for wounds with moist necrotic tissue or slough that needs to be removed.

B) Cover the wound with a transparent film dressing. - This is not an appropriate intervention, as transparent film dressings are not indicated for wounds with necrotic tissue or infection. Transparent film dressings are used for wounds with minimal drainage that need protection from external contamination and moisture loss.

C) Leave the wound open to air without any dressing. - This is not an appropriate intervention, as leaving the wound open to air without any dressing can expose it to further trauma and infection. Wounds need to be covered with an appropriate dressing that maintains a moist environment and supports wound healing.

A. Alginate dressing B. Foam dressing C. Gauze dressing D. Hydrogel dressing

Correct Answer is D

Explanation

Correct answer: D) Hydrogel dressing

Rationale: The nurse should use a hydrogel dressing to promote autolytic debridement of the wound. Autolytic debridement is a natural process that uses the body's own enzymes and moisture to liquefy and remove necrotic tissue from a wound. Hydrogel dressings provide hydration and moisture to dry wounds and facilitate autolytic debridement.

Incorrect options:

A) Alginate dressing - This is not an appropriate dressing for autolytic debridement, as alginate dressings are used for wounds with moderate to heavy exudate that need absorption and hemostasis. Alginate dressings form a gel-like substance when in contact with wound fluid and help to maintain a moist environment for wound healing.

B) Foam dressing - This is not an appropriate dressing for autolytic debridement, as foam dressings are used for wounds with moderate to heavy exudate that need insulation and protection. Foam dressings have a soft and absorbent layer that cushions the wound and prevents maceration of the surrounding skin.

C) Gauze dressing - This is not an appropriate dressing for autolytic debridement, as gauze dressings are used for wounds with minimal to moderate exudate that need cleansing and packing. Gauze dressings can adhere to the wound surface and cause trauma and bleeding when removed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has a pressure ulcer on the sacrum. Which intervention should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has a black, dry, and hard eschar covering most of its surface. Which action should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to change a dressing on a client's surgical incision. Which type of dressing should the nurse use to promote autolytic debridement of the wound?

Correct Answer is D

Explanation

A nurse is caring for a client who has a pressure ulcer on the sacrum. Which intervention should the nurse perform first?

A client is receiving negative pressure wound therapy (NPWT) for a chronic wound on the lower leg. The nurse observes that the wound edges are approximated and granulation tissue is filling the wound bed. Which action should the nurse take?