The nurse is performing a routine dressing change for a patient 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.
Apply a hydrocolloidal gel dressing.
Increase the frequency of the dressing changes.
Replace the gauze with a transparent dressing.
The Correct Answer is B
Choice A rationale:
Leaving the dressing off would expose the wound to air and potential contamination, which could delay healing and increase the risk of infection.
While consulting with the healthcare provider is always an option, it's not necessary in this case as the nurse has the knowledge and skills to select an appropriate dressing.
Additionally, leaving the wound uncovered could cause pain and discomfort to the patient, as well as potentially disrupt the delicate granulation tissue that has already formed.
Choice C rationale:
Increasing the frequency of dressing changes could disrupt the healing process and irritate the wound bed.
It's generally recommended to change dressings only as often as necessary to keep the wound clean and moist. Excessive dressing changes can also be costly and time-consuming for both the patient and the healthcare provider. Choice D rationale:
Transparent dressings are not ideal for stage 3 pressure injuries with significant granulation tissue. These dressings are more suitable for wounds with minimal exudate and that are not actively healing. Transparent dressings can also adhere to the wound bed, causing pain and trauma upon removal.
Choice B rationale:
Hydrocolloidal gel dressings are a good choice for stage 3 pressure injuries with granulation tissue because they: Provide a moist wound environment, which promotes healing.
Absorb exudate, which helps to prevent maceration of the surrounding skin. Form a protective barrier over the wound, which helps to prevent infection.
Are comfortable for the patient and can be left in place for several days.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Colloidal oatmeal-based lotions can be soothing and moisturizing for dry, itchy skin, but they are not effective in treating the inflammation and scaling associated with psoriasis.
They do not address the underlying hyperproliferation of skin cells that is characteristic of psoriasis.
While they may provide temporary relief of symptoms, they are not a long-term solution for managing the condition.
Choice B rationale:
Topical corticosteroids are the mainstay of treatment for psoriasis.
They work by reducing inflammation, slowing the growth of skin cells, and easing itching and scaling. They come in a variety of strengths and formulations, including creams, ointments, gels, and foams.
The type of corticosteroid and the strength of the medication will depend on the severity of the psoriasis and the location of the lesions.
It's important to follow the healthcare provider's instructions for use carefully, as overuse of topical corticosteroids can lead to side effects such as thinning of the skin and rebound flares.
Choice C rationale:
Topical analgesics, such as lidocaine or benzocaine, can be used to temporarily relieve pain and itching associated with psoriasis.
However, they do not address the underlying inflammation and scaling, and they should not be used as a primary treatment for the condition.
They may be used as adjunctive therapy in conjunction with topical corticosteroids or other psoriasis medications.
Choice D rationale:
Topical antifungal medications are used to treat fungal infections of the skin, such as athlete's foot or ringworm. They are not effective in treating psoriasis, which is an autoimmune condition rather than a fungal infection.
Using a topical antifungal medication for psoriasis could potentially worsen the condition or lead to other skin problems.
Correct Answer is C
Explanation
Rationale for Choice A:
Serum Helicobacter pylori (H. pylori) antibody results are not directly relevant to the diagnosis or management of acute pancreatitis. While H. pylori infection can cause gastritis and peptic ulcers, it is not a common cause of pancreatitis.
Urine output amounts are important to monitor in patients with pancreatitis to assess for dehydration and kidney function. However, they are not as specific to the diagnosis of pancreatitis as other findings.
Rationale for Choice B:
Reports of chronic constipation are not typically associated with acute pancreatitis.
Serum gastrin levels are used to diagnose conditions such as Zollinger-Ellison syndrome, which is characterized by excessive acid production in the stomach. They are not relevant to the diagnosis of pancreatitis.
Rationale for Choice C:
Severity of nausea and vomiting are key symptoms of pancreatitis. The severity of these symptoms can help to gauge the severity of the pancreatitis and guide treatment decisions.
Serum amylase results are a highly sensitive and specific marker for pancreatitis. Elevated levels of amylase in the blood strongly suggest the presence of pancreatitis.
Rationale for Choice D:
Presence of bowel sounds can be variable in patients with pancreatitis and are not always reliable indicators of the severity of the condition.
Degree of abdominal pain is a subjective symptom that can be difficult to assess accurately. While it is an important symptom of pancreatitis, it is not as objective as other findings such as serum amylase levels.
Therefore, the most valuable information to report to the healthcare provider in this case is the severity of nausea and vomiting and serum amylase results.
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