The client states, "Why am I getting protein supplements while I'm healing from a bed sore?" What is the best response by the nurse?
"Because it is easy to digest."
"If you don't like it, you don't have to take it."
"These supplements have nothing to do with your wound."
"Protein has amino acids that promote wound healing."
The Correct Answer is D
Choice A reason: "Because it is easy to digest." is not the best response by the nurse. This is not a valid reason for giving protein supplements to a client with a bed sore. Protein supplements may or may not be easy to digest depending on the type and amount of protein and the client's digestive system. The ease of digestion is not the main goal of protein supplementation.
Choice B reason: "If you don't like it, you don't have to take it." is not the best response by the nurse. This is a dismissive and unprofessional response that does not address the client's question or concern. Protein supplements are prescribed for a reason and the client should be educated on the benefits and risks of taking or refusing them. The nurse should also respect the client's preferences and choices and offer alternatives if possible.
Choice C reason: "These supplements have nothing to do with your wound." is not the best response by the nurse. This is a false and misleading statement that contradicts the evidencebased practice of wound care. Protein supplements have a lot to do with wound healing as they provide the essential nutrients for tissue repair and regeneration. Protein deficiency can impair wound healing and increase the risk of infection and complications.
Choice D reason: "Protein has amino acids that promote wound healing." is the best response by the nurse. This is a factual and informative statement that explains the rationale for giving protein supplements to a client with a bed sore. Protein is composed of amino acids, which are the building blocks of cells and tissues. Amino acids are involved in various processes of wound healing, such as collagen synthesis, angiogenesis, and immune response. Protein supplementation can enhance wound healing and prevent protein malnutrition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: Color is an important indicator of the blood flow and oxygenation to the affected extremity. The nurse should compare the color of the skin, nails, and mucous membranes of the affected and unaffected extremities and look for any signs of pallor, cyanosis, or mottling. These signs can indicate ischemia, hypoxia, or impaired circulation, which can lead to tissue damage or necrosis.
Choice B reason: Temperature is another important indicator of the blood flow and oxygenation to the affected extremity. The nurse should compare the temperature of the skin of the affected and unaffected extremities by palpating with the back of the hand and look for any signs of warmth or coolness. These signs can indicate inflammation, infection, or reduced perfusion, which can affect the healing process or cause complications.
Choice C reason: Ecchymosis is not an indicator of the neurovascular status of the affected extremity. Ecchymosis is the discoloration of the skin caused by bleeding under the skin, which can result from trauma, surgery, or anticoagulant therapy. Ecchymosis is expected after an ORIF of a femur fracture and does not necessarily indicate a problem with the blood flow or oxygenation to the extremity.
Choice D reason: Skin integrity is not an indicator of the neurovascular status of the affected extremity. Skin integrity is the condition of the skin and its ability to resist damage, infection, or breakdown. Skin integrity can be affected by factors such as pressure, friction, moisture, or foreign bodies. The nurse should assess the skin integrity of the affected extremity and look for any signs of wounds, ulcers, or infections, but these signs do not reflect the neurovascular status of the extremity.
Choice E reason: Sensation is an important indicator of the nerve function and innervation of the affected extremity. The nurse should assess the sensation of the affected extremity by asking the client to report any numbness, tingling, or pain, or by testing the client's response to light touch, pressure, or temperature. These signs can indicate nerve damage, compression, or irritation, which can affect the mobility and function of the extremity.
Correct Answer is D
Explanation
Choice A reason: Blanching is not the term for black and necrotic tissue. Blanching is the temporary whitening of the skin when pressure is applied. It indicates that the blood flow is intact and the tissue is healthy.
Choice B reason: Cellulitis is not the term for black and necrotic tissue. Cellulitis is a bacterial infection of the skin and subcutaneous tissue. It causes redness, swelling, warmth, and pain in the affected area.
Choice C reason: Tunneling is not the term for black and necrotic tissue. Tunneling is a narrow channel or pathway that extends from the wound into the surrounding tissue. It indicates a deeper and more complex wound.
Choice D reason: Eschar is the term for black and necrotic tissue. Eschar is a thick, dry, and hard crust that forms over a wound. It indicates a severe tissue damage and impaired healing.
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