what are the steps in managing a patient with a pressure ulcer
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Nursing Elites

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1. What are the steps in managing a patient with a pressure ulcer?

Correct answer: A

Rationale: The correct answer is A: Clean the wound and apply a hydrocolloid dressing. This step is crucial in managing a pressure ulcer as it helps protect the ulcer from infection and promotes healing by creating a moist environment conducive to tissue repair. Choice B, debriding necrotic tissue and applying antibiotics, is more suitable for managing infected pressure ulcers but not as the initial step. Choice C, applying an alginate dressing and elevating the affected area, may be part of the management but is not the initial step. Choice D, using moisture-retentive dressings and repositioning frequently, is important for prevention but not the first step in managing an existing pressure ulcer.

2. When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.

3. A client is scheduled for a 12-lead ECG. Which of the following actions should the nurse include in the plan of care?

Correct answer: D

Rationale: During a 12-lead ECG, the client needs to remain still to obtain accurate readings. Therefore, instructing the client to remain still is essential. Choices A, B, and C are incorrect because fasting is not necessary for an ECG, providing a warm blanket is not a standard procedure, and applying cold compresses may interfere with the ECG results.

4. A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task?

Correct answer: A

Rationale: The correct answer is A: Yankauer catheter. The Yankauer catheter is specifically designed for oral suctioning, making it the most appropriate choice for this task. Choice B, the Bulb syringe, is typically used for suctioning small amounts of liquid from the nose or mouth. Choice C, the Suction catheter, is more commonly used for deep suctioning in the trachea or bronchi. Choice D, Sterile gloves, are necessary for infection control but are not the primary supply used for oral suctioning.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct answer is to check the client's capillary blood glucose level every 4 hours. Clients receiving TPN are at risk for hyperglycemia, so regular monitoring of blood glucose levels is essential to detect and manage hyperglycemia promptly. Administering TPN through a peripheral IV catheter (Choice A) is incorrect as TPN should be given through a central venous catheter to prevent complications. Heating the TPN solution to room temperature (Choice C) is unnecessary and not a standard practice. Weighing the client every 3 days (Choice D) is important for monitoring fluid status but is not the priority action when caring for a client receiving TPN.

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