On admission to the hospital, the nurse notes that the client has a sacral wound that is "yellow" in color. What wound treatment would the nurse expect the health care provider to order?
Promotion of oxygenation by enhancing air circulation around wound
Removal of nonviable tissue followed by a moist wound dressing
Use of barrier cream and a foam dressing
No treatment is necessary
The Correct Answer is B
Choice A rationale: Promotion of oxygenation by enhancing air circulation around the wound is not the primary treatment for a "yellow" wound.
Choice B rationale: Removal of nonviable tissue followed by a moist wound dressing is the expected treatment for a wound with yellow color, indicating the presence of slough (nonviable tissue).
Choice C rationale: Use of barrier cream and a foam dressing may be indicated for other types of wounds but may not address the specific issue of nonviable tissue in a "yellow" wound.
Choice D rationale: No treatment is necessary is not appropriate for a wound with evidence of nonviable tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A rationale: Diluting potassium elixir in juice is not a priority intervention for a critically elevated potassium level. Immediate actions are needed.
Choice B rationale: Monitoring intake and output is important, but it is not the highest priority when the potassium level is critically elevated.
Choice C rationale: Assessing the client for muscle weakness and flaccid paralysis is a high priority because hyperkalemia can lead to serious cardiac and neuromuscular complications.
Choice D rationale: Encouraging intake of orange juice or a banana may be appropriate for managing mild hypokalemia, but it is not the priority for a client with critically elevated potassium.
Choice E rationale: Obtaining a physician's order for cardiac monitoring is crucial, as hyperkalemia can lead to life-threatening cardiac dysrhythmias.
Correct Answer is B
Explanation
Choice A rationale: Injecting one mL of air into a vial before withdrawing 20 mg furosemide is an appropriate technique to equalize pressure in the vial.
Choice B rationale: Instructing a client to place a buccal medication under the client's tongue this is a method for administering sublingual medications. Buccal medications are placed between the cheek and the gum and allowed to dissolve slowly.
Choice C rationale: Pouring liquid medication to the 10 ml mark on a medication cup is acceptable, as long as the cup is held at eye level and the lowest point of the meniscus is used to measure the volume.
Choice D rationale: Selecting a 1 ml syringe with a 5/8 inch needle is suitable for giving heparin subcutaneously, as this ensures accuracy and minimizes tissue trauma.
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