The nurse is caring for a patient with a healing Stage II pressure ulcer. The wound is clean and granulating. Which health care provider’s order will the nurse question?

Consult a dietitian.

Apply a hydrogel dressing.

Clean the wound with hydrogen peroxide.

Use a low-air-loss therapy unit.

Answer and Explanation

The Correct Answer is C

The correct answer is C.

A: Consulting a dietitian is a beneficial order for a patient with a pressure ulcer. Proper nutrition, especially adequate protein intake, is crucial for wound healing. A dietitian can help ensure the patient receives the necessary nutrients to support tissue repair and recovery.

B: Applying a hydrogel dressing is appropriate for a clean, granulating Stage II pressure ulcer. Hydrogel dressings maintain a moist wound environment, which promotes healing and provides pain relief. They are suitable for wounds with minimal to moderate exudate.

C: Cleaning the wound with hydrogen peroxide is not recommended for a healing pressure ulcer. Hydrogen peroxide can damage healthy granulating tissue and delay the healing process. It is better to use saline or a wound cleanser that does not harm the new tissue.

D: Using a low-air-loss therapy unit is beneficial for patients with pressure ulcers. These units help reduce pressure on the skin, improve circulation, and prevent further skin breakdown. They are an effective part of pressure ulcer management.

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Correct Answer is B

Explanation

A: Chewing sublingual medication is incorrect. Sublingual medications are designed to dissolve under the tongue for rapid absorption into the bloodstream.

B: Letting the medication dissolve completely is correct. This ensures that the medication is absorbed properly and works effectively.

C: There is no restriction on drinking juice with sublingual medication unless specified by the healthcare provider. This statement does not indicate a clear understanding of sublingual administration.

D: Placing the medication between the cheek and gum is incorrect for sublingual medications. This method is used for buccal medications, not sublingual ones.

A. Complete proper documentation of the medication error in the patient’s chart. B. Return to the room to check and assess the patient. C. Administer the antidote to the patient immediately. D. Alert the charge nurse that a medication error has occurred.

Correct Answer is B

Explanation

A: Completing proper documentation of the medication error is important but should not be the first action. Immediate assessment of the patient is more critical.

B: Returning to the room to check and assess the patient is the first priority. The nurse needs to determine if the patient has experienced any adverse effects from the medication error and provide appropriate care.

C: Administering the antidote to the patient immediately is only necessary if the medication given has a known antidote and the patient is showing signs of adverse effects. Assessment should come first.

D: Alerting the charge nurse that a medication error has occurred is important for reporting and follow-up but should follow the immediate assessment and care of the patient.

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The nurse is caring for a patient with a healing Stage II pressure ulcer. The wound is clean and granulating. Which health care provider’s order will the nurse question?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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