The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Leave the dressing off until consulting with the healthcare provider.

Replace the gauze with a transparent dressing.

Increase the frequency of the dressing changes.

Apply a hydrocolloid gel dressing.

Answer and Explanation

The Correct Answer is D

Choice A reason: Leaving the dressing off is not advisable as it can expose the wound to potential infection and delay healing.

Choice B reason: A transparent dressing may not be the best choice for a stage 3 pressure injury with significant granulation tissue.

Choice C reason: Increasing the frequency of dressing changes without specific orders may not be necessary and could disrupt the healing process.

Choice D reason: A hydrocolloid gel dressing is appropriate for a stage 3 pressure injury as it maintains a moist environment, which is conducive to wound healing and granulation.

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Correct Answer is B

Explanation

Choice A reason: While using multiple people can increase safety, it is not the primary purpose of the log rolling technique.

Choice B reason: The log rolling technique is specifically designed to maintain straight spinal alignment, especially in patients with suspected spinal injuries, to prevent further injury.

Choice C reason: Reducing skin damage is a benefit of proper patient handling, but it is not the main reason for using the log rolling technique.

Choice D reason: Decreasing the risk of back injury to nurses is important, but the primary purpose of the log rolling technique is to protect the patient's spinal integrity.

A. Oatmeal, cream of wheat, pureed liquid. B. Pureed beans, liquid protein supplements, milkshake. C. Pureed carrots, creamed soup, ice cream. D. Carbonated drinks, gelatin, broth. E. Water, tea, ice chips.

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

Explanation

Choice A reason: Oatmeal, cream of wheat, and pureed liquids are not clear liquids and are not appropriate for a clear liquid diet.
Choice B reason: Pureed beans, liquid protein supplements, and milkshakes are not considered clear liquids and should not be included in a clear liquid diet.
Choice C reason: Pureed carrots, creamed soup, and ice cream are not clear liquids because they are not transparent and cannot be consumed on a clear liquid diet.
Choice D reason: Carbonated drinks, gelatin, and broth are considered clear liquids because they are transparent and can be consumed on a clear liquid diet.
Choice E reason: Water, tea without milk or cream, and ice chips are clear liquids and are appropriate for a clear liquid diet.

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The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

Correct Answer is B

Explanation

When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume? Select all that apply.

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

Explanation

The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

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