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 C
Explanation
A: Identifying the type of sedative is important for treatment but is not the immediate priority.
B: Inserting a large-bore IV catheter is necessary for administering medications and fluids but is not the first priority.
C: Ensuring an adequate airway is the priority action. Maintaining airway patency is crucial to prevent respiratory complications and ensure the client receives adequate oxygen.
D: Preparing the appropriate antagonist is important but should follow the immediate action of ensuring an adequate airway.
Correct Answer is D
Explanation
A: Proceeding to measure the oral temperature immediately after the client has eaten ice chips is not appropriate. The cold temperature can affect the accuracy of the reading.
B: Documenting that the nurse was unable to measure the client’s temperature is unnecessary. The nurse can take steps to ensure an accurate measurement by waiting.
C: Providing the client a sip of warm water and waiting 5 minutes is not sufficient to counteract the effect of the ice chips on the oral temperature reading.
D: Waiting 30 minutes before measuring the oral temperature is the correct action. This allows time for the oral cavity to return to its normal temperature, ensuring an accurate reading.
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