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 D
Explanation
Diminished breath sounds in a client admitted with pneumonia. This is because diminished breath sounds indicate a worsening of the respiratory condition and a possible complication of pneumonia, such as atelectasis or pleural effusion.
The healthcare provider should be notified immediately to assess the client and order appropriate interventions.
Choice A is wrong because a report of joint pain by a client who recently started taking arthritis medication is not an urgent finding.
Joint pain is a common symptom of arthritis and may take some time to improve with medication.
The nurse should monitor the client’s pain level and administer analgesics as prescribed.
Choice B is wrong because report of decreased appetite and difficulty sleeping is not an immediate concern.
These are nonspecific symptoms that may be related to stress, anxiety, depression, or other factors.
The nurse should explore the possible causes of these symptoms and provide emotional support and education to the client.
Choice C is wrong because a weight loss of two pounds in a client admitted to congestive heart failure is not a critical finding.
Weight loss may indicate a reduction of fluid retention, which is a desired outcome for clients with heart failure.
The nurse should monitor the client’s weight daily and report any significant changes to the health care provider.
Normal ranges for weight, appetite, sleep, joint pain, and breath sounds vary depending on the individual’s age, gender, height, activity level, medical history, and other factors.
Correct Answer is A
Explanation
This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.
The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.
Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.
Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.
Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.
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