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 C

Explanation

Choice A reason: While a medication reference guide is useful, it does not replace the need for clarification from the prescribing healthcare provider regarding dosage discrepancies.

Choice B reason: The nursing unit charge nurse can be a resource, but the prescriber should be the first contact for medication orders.

Choice C reason: The healthcare provider who prescribed the medication is the most appropriate resource to clarify and potentially correct the dosage of the oral antibiotic.

Choice D reason: The hospital pharmacist is a valuable resource for medication information and can be consulted, but the prescriber should first be contacted to address the discrepancy in dosages.

A. Offer fruit juice at least twice during both the day and evening shifts. B. Encourage the client to eat all of the meals that are sent. C. Lower the bed prior to helping the client to move up in bed. D. Have the client hold a pillow over the abdomen to cough and deep breathe.

Correct Answer is D

Explanation

Choice A reason: Offering fruit juice is part of good nutrition and hydration but does not directly assist with the client's breathing difficulty.

Choice B reason: Encouraging the client to eat all meals is important for nutritional support, but it is not the most critical action related to the client's immediate respiratory comfort.

Choice C reason: Lowering the bed may be a safety measure but does not address the client's need for respiratory support.

Choice D reason: Having the client hold a pillow over the abdomen can help splint the chest while coughing, reducing discomfort and facilitating deep breathing, which is essential for a client with emphysema experiencing difficulty breathing.

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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

Correct Answer is C

Explanation

A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

Correct Answer is D

Explanation

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

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