Which technique is most appropriate for a nurse to use when cleansing a pressure ulcer?
Cleanse using hydrogen peroxide followed by betadine solution.
Cleanse the wound gently from the outer edges towards the center.
Cleanse using 4x4 gauze to the wound and surrounding skin three times.
Cleanse from the innermost point outwards with a circular movement.
The Correct Answer is D
Cleanse from the innermost point outwards with a circular movement. This technique reduces the risk of contaminating the wound with bacteria from the surrounding skin.
Some possible explanations for the other choices are:
Choice A is wrong because hydrogen peroxide and betadine solution can damage healthy tissue and delay wound healing.
Choice B is wrong because cleansing the wound from the outer edges towards the center can introduce bacteria from the skin into the wound.
Choice C is wrong because using 4x4 gauze to the wound and surrounding skin three times can cause trauma and bleeding to the wound.
Normal ranges for pressure ulcer stages are:
- Stage I: A reddened, painful area on the skin that does not turn white when pressed.
- Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
- Stage III: The skin develops an open, sunken hole called a crater or ulcer. The tissue below the skin is damaged.
- Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
The correct answers are Choices A, B, C, and D.Choice A rationale:Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale:Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale:Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale:Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale:Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.
Correct Answer is D
Explanation
Insulin injection sites are rotated to prevent lipodystrophy, which is a condition where the fat tissue under the skin becomes lumpy or dented due to repeated injections.
Lipodystrophy can affect the absorption and effectiveness of insulin.
Choice A is wrong because bruising is not a common complication of insulin
injections. Bruising can occur if the needle hits a blood vessel, but this can be avoided by using a new needle each time and applying gentle pressure after the injection.
Choice B is wrong because infection is not a common complication of insulin
injections. Infection can occur if the skin is not cleaned properly before the injection or if the needle is contaminated, but this can be prevented by washing the hands and using alcohol swabs.
Choice C is wrong because bleeding is not a common complication of insulin
injections. Bleeding can occur if the needle hits a blood vessel, but this can be minimized by using a new needle each time and applying gentle pressure after the injection.
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