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
Storing the medication at room temperature is appropriate for ipratropium inhalers. This ensures the medication remains effective and safe for use.
Choice B rationale
Attaching a spacer device to the inhaler is recommended for patients using ipratropium inhalers. A spacer helps deliver the medication more effectively to the lungs and reduces the risk of side effects.
Choice C rationale
Rinsing the mouth after each use of the inhaler is a good practice to prevent oral thrush and other side effects. It is a recommended step in the proper use of inhalers.
Choice D rationale
Priming the inhaler with 7 pumps is excessive. Typically, inhalers need to be primed with 2-4 pumps before first use or if they haven’t been used for a while. Over-priming can waste medication and indicate a need for additional teaching.