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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

While teaching the client about infection prevention measures is important, it is not the most crucial action in this situation. The client is already exhibiting symptoms and has potentially been spreading the virus.

Focusing on isolation at this point is a more effective way to prevent further transmission.

Additionally, the client may be too ill to fully comprehend or adhere to instructions regarding masks, handwashing, and social distancing.

Choice B rationale:

Isolation is the most essential action to prevent the spread of COVID-19 to others. This is because:

COVID-19 is highly contagious and can spread through respiratory droplets produced when an infected person coughs, sneezes, or talks.

Isolation physically separates the infected person from others, reducing the risk of transmission.

Proper PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the infectious droplets, further minimizing the risk of spread.

Choice C rationale:

Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus. However, it is not as immediate a priority as isolating the client to prevent further transmission.

Choice D rationale:

Counseling family members about monitoring for symptoms is also important for early identification and containment of potential cases. However, it does not directly address the immediate risk of transmission from the actively symptomatic client.

A. Diabetes Mellitus B. Hypoglycemia C. Hyperglycemia D. Prediabetes

Correct Answer is A

Explanation

Choice A rationale:

Hemoglobin A1C (HbA1C) is a blood test that reflects a person's average blood glucose levels over the past 2-3 months. It's considered the gold standard for diagnosing and monitoring diabetes.

An HbA1C level of 8.29% is significantly elevated above the reference range of 4-5.99%, indicating a high probability of diabetes.

The patient's HbA1C has also increased from 7.59% three months ago, suggesting a worsening of glycemic control.

Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose levels due to impaired insulin production or action, or both.

Common symptoms of diabetes include increased thirst, frequent urination, fatigue, blurred vision, and slow-healing wounds.

Early diagnosis and treatment of diabetes are crucial to prevent complications such as heart disease, stroke, kidney disease, nerve damage, and vision loss.

Choice B rationale:

Hypoglycemia refers to abnormally low blood glucose levels, typically below 70 mg/dL. It's often caused by excessive insulin or medication, missed meals, or strenuous exercise.

The patient's HbA1C level of 8.29% does not support a diagnosis of hypoglycemia.

Choice C rationale:

Hyperglycemia refers to abnormally high blood glucose levels, typically above 180 mg/dL. It can be caused by diabetes, stress, infection, or certain medications.

While the patient's HbA1C level does indicate hyperglycemia, it's specifically the pattern of elevated HbA1C over time that points to a diagnosis of diabetes mellitus, rather than transient hyperglycemia.

Choice D rationale:

Prediabetes is a condition where blood glucose levels are higher than normal, but not high enough to be classified as diabetes. People with prediabetes are at increased risk of developing diabetes.

The patient's HbA1C level of 8.29% is above the threshold for prediabetes, which is typically 5.7-6.4%.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

The patient's Hemoglobin A1C today is 8.29% and was 7.59% three months ago. The reference range is 4 to 5.99%. What is the likely diagnosis?

Correct Answer is A

Explanation

The nurse is preparing a teaching plan for a group of clients who were found to be HIV positive within the last year. Members of the group express an interest in learning about the pathology of AIDS.The nurse should explain that HIV acts in which way to suppress the immune system?

The patient’s vital signs are as follows: Temperature 97.5 F (36.4 C), Heart rate 104 beats/minute, Respirations 29 breaths/minute, Blood pressure 119/82 mm Hg, Oxygen saturation 89%. Oxygen mask applied.What should the nurse do next?

A client receives a prescription for ophthalmic ketorolac.Prior to administering the medication, the nurse should review the medical record for which condition?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client’s serum laboratory values is most important for the nurse to review?

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?