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 B
Explanation
Choice A rationale
Obtaining vital signs every 2 hours is important for monitoring the patient’s overall condition, but it is not the immediate priority following the surgical removal of glass from the eye.
Choice B rationale
Providing an eye shield to be worn while sleeping is crucial to protect the eye from injury and promote healing after the surgical removal of glass. This intervention helps prevent accidental rubbing or pressure on the eye.
Choice C rationale
Teaching a family member to administer eye drops is important for ongoing care, but it is not the immediate priority following the procedure. The immediate focus should be on protecting the eye and ensuring proper healing.
Choice D rationale
Encouraging deep breathing and coughing exercises is important for preventing respiratory complications, but it is not directly related to the immediate care of the eye following the surgical removal of glass.
Correct Answer is D
Explanation
Choice A rationale
Total protein levels are not directly related to the symptoms of pallor and fatigue. While important, they do not provide immediate insight into the client’s current condition.
Choice B rationale
Sodium levels are crucial for overall health but are not directly related to the symptoms of pallor and fatigue. Monitoring sodium is important for fluid balance but not for diagnosing anemia.
Choice C rationale
Glucose levels are essential for managing diabetes and other metabolic conditions but are not directly related to the symptoms of pallor and fatigue. Monitoring glucose is important for overall health but not for diagnosing anemia.
Choice D rationale
Hemoglobin levels are directly related to the symptoms of pallor and fatigue. Diclofenac, an NSAID, can cause gastrointestinal bleeding, leading to anemia. Therefore, reviewing hemoglobin levels is crucial in this scenario.