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 A

Explanation

A: The correct instruction is to hold the cane on the right side, which is the side opposite the weaker leg. This provides better support and balance for the weaker side.

B: Removing the rubber tip from the cane is not recommended. The rubber tip provides traction and stability, reducing the risk of slipping.

C: Advancing the right leg and the cane together is incorrect. The cane should move with the weaker leg (left leg in this case) to provide support during ambulation.

D: Placing the cane 61 cm (24 in) in front of the feet is too far. The cane should be placed about 15-25 cm (6-10 in) in front of the feet to provide optimal support and balance.

A. Antiplatelet aggregate B. Analgesic C. Antipyretic D. Anti-inflammatory

Correct Answer is A

Explanation

A: Aspirin is given as an antiplatelet aggregate to prevent blood clots in clients with a history of myocardial infarction. It inhibits platelet aggregation, reducing the risk of further cardiac events.

B: While aspirin has analgesic properties, this is not the primary reason for its use in clients with a history of myocardial infarction.

C: Aspirin also has antipyretic properties, but this is not the reason for its use in preventing cardiac events.

D: Aspirin’s anti-inflammatory properties are beneficial, but the primary reason for its use in myocardial infarction is its antiplatelet effect.

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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

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