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
Pulse oximetry works by measuring the amount of light that passes through your finger and reaches a sensor on the other side.
The amount of light that is absorbed by your blood depends on how much oxygen it carries. Nail polish can block or reflect some of the light, making it harder for the pulse oximeter to get an accurate reading of your oxygen level.
Choice A is wrong because the color of your nailbed is not relevant for pulse oximetry.
The pulse oximeter does not measure the color of your nailbed, but the amount of light that passes through it.
Choice C is wrong because the sensor does not react with the nail polish causing an allergic reaction.
The sensor is a non-invasive device that does not touch your skin or nail polish directly.
Choice D is wrong because the chemicals in the nail polish do not cause falsely decreased readings of your oxygen level.
The chemicals in the nail polish do not affect the amount of oxygen in your blood, but only the amount of light that reaches the sensor.
Normal ranges for pulse oximetry vary depending on your health condition and altitude, but generally they are between 95% and 100%. If your pulse oximetry reading is lower than 90%, you may have hypoxia, which means your tissues are not getting enough oxygen.
Correct Answer is B
Explanation
Face the client while speaking and ask them to verify understanding. This intervention would help the client to read the nurse’s lips and confirm the message.
It would also show respect and empathy for the client’s condition.
Choice A is wrong because using exaggerated mouth and hand movements when speaking can be distracting and insulting to the client.
It can also distort the words and make them harder to understand.
Choice C is wrong because standing in front of a light when speaking to the client can create glare and make it difficult for the client to see the nurse’s face.
Touching the client to be sure they know where you are can be startling and unnecessary if the client is not visually impaired.
Choice D is wrong because obtaining an interpreter for sign language is inappropriate unless the client knows sign language.
Not all hearing-impaired clients use sign language, and some may prefer other methods of communication.
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