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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A: Keeping a fluorescent ceiling light on at night can be too bright and disrupt sleep. A nightlight is a better option for safety without disturbing sleep.
B: Keeping the walker at the end of the bed is not ideal. The walker should be within easy reach to prevent falls when getting out of bed.
C: Placing a bath seat in the shower is a good safety measure. It provides stability and reduces the risk of slipping and falling while bathing.
D: Placing an area rug at the entry of the bathroom can be a tripping hazard. It is better to use non-slip mats that are securely placed.
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