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 B
Explanation
Palms, soles and nails.
Melanoma is a type of skin cancer that can develop in any color skin, including dark or black skin.
However, melanoma on dark skin is not related to sun exposure and can start in places that get little sun. That includes the palms of your hands, soles of your feet, nails, and inside your mouth, anal, and genital areas.
Choice A is wrong because eyes, ears, lips, and scalp are not common areas for melanoma in people of color.
Choice C is wrong because head, neck and trunk are more likely to be affected by sun exposure and other types of skin cancer than melanoma in people of color.
Choice D is wrong because lower legs and back are also more exposed to sun and other types of skin cancer than melanoma in people of color.
Correct Answer is B
Explanation
The client practices meditation for 20 minutes once a day. This is an example of an adaptive coping strategy, which is a cognitive or behavioral effort to manage stressful conditions or associated emotional distress.
Meditation can help reduce tension, enhance relaxation, and promote well-being.
Choice A is wrong because the client consumes 3 glasses of wine after a stressful day at work. This is an example of an avoidance coping strategy, which is an attempt to reduce stress by avoiding dealing directly with the problem.
Alcohol consumption can have negative effects on physical and mental health, and does not address the source of stress.
Choice C is wrong because the client keeps all unresolved conflict to themselves. This is an example of an emotion-focused coping strategy, which is an attempt to regulate the emotional distress caused by a stressor.
However, this strategy can be maladaptive if it involves suppressing or denying emotions, which can lead to increased psychological distress and poor interpersonal relationships.
Choice D is wrong because the client consumes a half gallon of ice cream after an argument with a coworker. This is another example of an avoidance coping strategy, which is an attempt to reduce stress by avoiding dealing directly with the problem.
Ice cream consumption can have negative effects on physical health, such as obesity and diabetes, and does not address the source of stress.
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