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
Isoniazid is an antitubercular drug used to treat active tuberculosis. The effectiveness of this medication is evaluated by observing a decrease in symptoms such as cough and sputum production. This indicates that the infection is being controlled and the bacteria are being eradicated.
Choice B rationale
A positive sputum smear and culture would indicate the presence of active tuberculosis bacteria, suggesting that the treatment is not effective. Therefore, this is not an expected outcome of effective treatment.
Choice C rationale
Decreased appetite and weight loss are not indicators of the effectiveness of tuberculosis treatment. In fact, these symptoms could indicate a worsening of the condition or side effects of the medication.
Choice D rationale
Vertigo and tinnitus are not related to the effectiveness of tuberculosis treatment. These symptoms could be side effects of the medication but do not indicate the success of the treatment.
Correct Answer is A
Explanation
Choice A rationale
Postural drainage involves placing the client in various positions to facilitate the drainage of secretions from different parts of the lungs. Typically, the client may be placed in five positions: head down, prone, right and left lateral, and sitting upright.
Choice B rationale
Performing postural drainage immediately after meals is not recommended as it can cause nausea, vomiting, and aspiration. It is best to perform the procedure before meals.
Choice C rationale
Obtaining an arterial blood gas (ABG) prior to the procedure is not a standard requirement for postural drainage. ABGs are typically obtained to assess the client’s respiratory status but are not necessary for the procedure itself.
Choice D rationale
Instructing the client to breathe shallow and fast is not appropriate for postural drainage. The client should be encouraged to breathe slowly and deeply to help keep the airways open and facilitate the drainage of secretions.