The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
Increase the frequency of the dressing changes.
Leave the dressing off until consulting with the healthcare provider.
Apply a hydrocolloidal gel dressing.
Replace the gauze with a transparent dressing.
The Correct Answer is C
Choice A rationale
Increasing the frequency of dressing changes may not be necessary and could potentially disrupt the healing process. The type of dressing used is more important for managing the wound.
Choice B rationale
Leaving the dressing off until consulting with the healthcare provider is not recommended as it can expose the wound to infection and delay healing.
Choice C rationale
Applying a hydrocolloidal gel dressing is appropriate for a stage 3 pressure injury with significant granulation. Hydrocolloidal dressings provide a moist environment that promotes healing and protects the wound from contamination.
Choice D rationale
Replacing the gauze with a transparent dressing may not provide the necessary moisture and protection for a stage 3 pressure injury. Hydrocolloidal dressings are more suitable for this type of wound.
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Correct Answer is A
Explanation
Choice A rationale
Reported history of alcoholism is the most important assessment finding to address before administering terbinafine HCL. Terbinafine is metabolized by the liver, and clients with a history of alcoholism may have impaired liver function, increasing the risk of hepatotoxicity. Monitoring liver function and assessing for signs of liver damage are crucial before starting treatment.
Choice B rationale
Toenails appear thick and yellow is a common symptom of fungal toenail infection, but it is not the most critical assessment finding to address before administering terbinafine HCL. The focus should be on assessing liver function.
Choice C rationale
Employed as a construction worker is not the most critical assessment finding to address before administering terbinafine HCL. While occupational exposure to fungi may be relevant, the primary concern is liver function.
Choice D rationale
White blood cell count of 8,500/mm³ (8.5 x 10⁹/L) is within the normal range and is not the most critical assessment finding to address before administering terbinafine HCL. The primary concern is liver function.
Correct Answer is D
Explanation
Choice A rationale
A chest X-ray or computed tomography (CT) scan can show abnormalities in the lungs that are suggestive of tuberculosis (TB), but they cannot definitively diagnose TB. These imaging tests can reveal changes in the lungs, such as nodules, inflammation, or fluid buildup, which can be caused by TB or other conditions. Therefore, a chest X-ray or CT scan alone is not sufficient to diagnose TB.
Choice B rationale
A hemoccult test on sputum collected from hemoptysis is not a diagnostic test for TB. It is a test for blood in the stool, which can be a symptom of TB but is not specific to TB. Hemoptysis, or coughing up blood, can occur in various conditions, including bronchitis, pneumonia, lung cancer, and TB. The hemoccult test cannot differentiate between these causes, making it an unreliable test for diagnosing TB.
Choice C rationale
A positive purified protein derivative (PPD) skin test indicates exposure to TB but does not confirm active infection. The PPD skin test involves injecting a small amount of tuberculin, a protein derived from Mycobacterium tuberculosis, into the skin. If a person has been exposed to TB, their immune system will react to the tuberculin, causing a raised red bump to appear at the injection site. However, a positive PPD skin test does not necessarily mean that a person has active TB infection. It could also mean that they have been exposed to TB in the past but have successfully fought off the infection. Further testing, such as a sputum culture, is needed to confirm the diagnosis of TB.
Choice D rationale
A sputum culture positive for Mycobacterium tuberculosis is the definitive diagnostic test for TB. It involves collecting a sample of sputum, which is the mucus coughed up from the lungs, and culturing it in a laboratory to see if Mycobacterium tuberculosis, the bacteria that causes TB, grows. This test is highly specific for TB, meaning that a positive result is almost always indicative of TB infection. It is also sensitive, meaning that it can detect TB infection even when there are few bacteria present.