A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother?
a. Change the patient's bedding frequently.
b. Use a hydrocolloid dressing over the ulcer.
c. Record the size and appearance of the ulcer weekly.
d. Change the patient's position at least every 2 hours.
Question 2The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer?
a. Soak the old dressings with sterile saline 30 minutes before removing them.
b. Pour sterile saline onto the new dry dressings after the wound has been packed.
c. Apply antimicrobial ointment before repacking the wound with moist dressings.
d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.
Question 3The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas
Question 4A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure
Question 5A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8 F (38.7 C). Which action by the nurse is most appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Give the prescribed PRN aspirin (Ascriptin) 650 mg.
d. Check the patient's oral temperature again in 4 hours.
Quick Reply
