The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.
What actions should the nurse implement?
Instruct the unlicensed assistive personnel to frequently offer oral fluids.
Prepare to implement a pressure redistribution mattress.
Explain to the client that the wound needs debridement.
Obtain hemoglobin of the side to check for anemia and sensitivity.
The Correct Answer is B
Pressure redistribution is an important part of preventing and treating pressure sores1.
Choice A is not the answer because offering oral fluids does not directly address the issue of pressure sores.
Choice C is not the answer because debridement is a surgical procedure that removes dead tissue from a wound and may not be necessary in this case.
Choice D is not the answer because checking for anemia and sensitivity does not directly address the issue of pressure
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The UAP is correctly pulling the client’s auricle up and back and preparing to insert the thermometer1.
Choice A is incorrect because it is not necessary to remind the UAP to locate the thermometer before gently inserting it into the ear.
Choice B is incorrect because the UAP is already demonstrating the correct technique for pulling the client’s auricle up and back1.
Choice C is incorrect because it is not necessary to advise the UAP to hold the thermometer securely in place to obtain the measurement.
Correct Answer is B
Explanation
Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.
When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration1.
Choice A is incorrect because brushing an unconscious client’s teeth should not be avoided.
In fact, it is recommended that you brush your teeth at least once every four hours1.
Choice C is incorrect because unconscious clients need regular mouth care just like conscious clients2.
Choice D is incorrect because positioning the unconscious client upright is not the best method.
Instead, they should be placed in a side-lying position to prevent aspiration1.
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