The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

Debride the wound.

Manage drainage from the wound.

Document the wound.

Monitor the wound.

Answer and Explanation

The Correct Answer is A

A: Debriding the wound is the next step for a black (necrotic) pressure ulcer. Removing the dead tissue is essential to promote healing and prevent infection.

B: Managing drainage is important for wound care but is not the immediate next step for a necrotic ulcer.

C: Documenting the wound is necessary but does not address the need for debridement.

D: Monitoring the wound is important, but active intervention (debridement) is required for a necrotic ulcer to promote healing.

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Correct Answer is ["B","D","E"]

Explanation

A: A client with lactose intolerance does not have an increased risk of aspiration while eating. Lactose intolerance affects the digestive system, causing symptoms like bloating and diarrhea when consuming dairy products, but it does not impact swallowing.

B: A client who has had a cerebrovascular accident (CVA) or stroke is at increased risk of aspiration. Strokes can affect the muscles involved in swallowing, leading to dysphagia (difficulty swallowing) and increasing the risk of food or liquid entering the airway.

C: A client who has had prolonged diarrhea is not typically at increased risk of aspiration. Diarrhea affects the gastrointestinal system but does not directly impact the swallowing mechanism.

D: A client who has had trauma to the head and neck is at increased risk of aspiration. Such trauma can damage the structures involved in swallowing, leading to dysphagia and a higher likelihood of aspiration.

E: A client who is 4 hours postoperative following a leg amputation with general anesthesia is at increased risk of aspiration. General anesthesia can depress the gag reflex and swallowing function, making it easier for food or liquid to enter the airway during the immediate postoperative period.

A. Nasal cannula B. Simple face mask C. Aerosol mask D. Face tent

Correct Answer is B

Explanation

A: A nasal cannula delivers a lower concentration of oxygen, typically between 24-44% FIO2, and is used at flow rates of 1-6 L/min. It is not suitable for delivering 40-60% FIO2.

B: A simple face mask can deliver 40-60% FIO2 at flow rates of 5-8 L/min. It covers the nose and mouth, providing a higher concentration of oxygen compared to a nasal cannula.

C: An aerosol mask is used for delivering humidified oxygen or medications via nebulization. It can deliver varying concentrations of oxygen but is not specifically designed for 40-60% FIO2 at 5-8 L/min.

D: A face tent is used for patients who cannot tolerate a mask, such as those with facial trauma or claustrophobia. It provides humidified oxygen but does not deliver a precise FIO2 concentration.

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The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

Which oxygen delivery device can deliver 40-60% FIO2 and is from 5-8 L/min?

Correct Answer is B

Explanation

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