Question

1. Mr. Bryson has a stage 3 sacral pressure ulcer that is draining a large amount of purulent discharge. Which of the following wound care products would be the most appropriate choice for this wound?

a) Hydrogel

b) Hydrocolloid

c) Gauze dressing

d) Polyurethane

2. In order to prevent atelectasis in Mr. Bryson, which of the following interventions would the nurse promote?

a) Daily ambulation

b) Posturnal drainage

c) Slow abdominal breathing

d) Chest percussion and vibration

3. Which of the following nurse interventions should be included in Mr. Bryson’s daily routine care to promote his skin integrity?

a) Check the sheets for cleanliness and change them daily

b) Remind him to shift weight every 15 minutes when in a chair

c) Complete a risk assessment tool, such as the Braden scale q shift

d) Apply a petroleum-based product to moisturize areas of bony prominence

4) Mr. Bryson has shown the nurse a list of laxatives and says that the doctor has instructed to take a bulk-forming laxatives. Which of the following should the nurse recommend to him?

a) bisacodyl (Dulcolax)

b) docusate sodium (Colace)

c) psyllium mucilloid (Metamucil)

d) magnesium hydroxide (Milk of Magnesia)

5, The nurse believes that Mr. Bryson has developed a Deep Vein Thrombus in his right leg. Which of the following assessment findings is consistent with DVT?

a) Bilateral swelling in both feet

b) No pedal in the right foot

c) Decrease sensation in both feet

d) Unilateral swelling in the right calf

6. Which of the following foods could contribute to Mr. Bryson’s risk for developing renal calculi?

a)) Orange juice

b) Bananas

c) Yogurt

d) Eggs

7..A patient is requesting analgesic for breakthrough pain four times in a 24-hourperiod. Which intervention can the nurse promote to prevent further episodes of this type of pain?

a) Administer the prn analgesic medications more frequently

b) Record the pain patterns and effects of all medications

c) Provide adjuvant medication based on when pain is experienced

d)) Advocate that the dosage of “around the clock” medication be reviewed.

Answer 1

1) A decubitus ulcer is also known as a pressure ulcer, pressure sore, or bedsore. It’s an open wound on skin. Decubitus ulcers often occurs on bony prominences. option b and d are more accurate

Hydrocolloid dressings form an occlusive barrier over the wound. It maintains a moist wound environment and preventing bacterial contamination. A gel is formed when wound exudate comes in contact with the dressing. This gel have fibrinolytic properties enhances wound healing and protect against secondary infection, and insulate the wound from contaminants

Polyurethane foams are available in a number of different forms and a variety of shapes and sizes, with or without adhesive border prevent maceration or leakage, the dressing must overlap the wound bed by at least 2-3cm.

2) All options are correct. Atelectasis is defined as partial or complete collapse of alveoli. Nursing interventions focussed on

Performing deep-breathing exercises (incentive spirometry) and using a device to assist with deep coughing helps to remove secretions and increase lung volume.
Positioning head lower than the chest (postural drainage). This allows mucus to drain better from the bottom of your lungs.
Tapping on chest over the collapsed area to loosen mucus. This technique is called percussion.
Early ambulation facilitates mobilization of secretions
3) Impaired skin integrity occurs from prolonged pressure, irritation of the skin, and/or immobility, leading to the development of pressure ulcers. The Braden Scale, a widely used valid risk-assessment use for pressure ulcer risk assessment. Shear and friction rub will trigger pressure ulcer. Application of petroleum-based product to moisturize areas of bony prominence provide skin with adequate moisture.
4) Option c . Bulk-forming laxatives absorb liquid in the intestines. psyllium mucilloid (Metamucil) increases the bulkiness of stool, that helps to cause movement of the intestines. It also works by increasing the amount of water in the stool, making the stool softer and easier to pass.

5) Option B and D.

Deep vein thrombosis, or DVT, occurs when a blood clot forms in one of the deep veins of the body. Symptoms of DVT occur in the leg affected by the blood clot and include Swelling, absence of pedal pulse,Pain or tenderness.

6) option C,D . Yogurt is rich in calcium consuming in excess triggers risk of developing renal calculi. Eggs is rich in oxalate excess consumption precipitates oxalate stones in kidneys.

7) option c . Breakthrough pain is defined as sudden increase in chronic pain it occurs during serious illness like cancer,arthritis, postoperative when the effect of administered pain medication efficacy wears off. Provide adjuvant medication based on when pain is experienced like opioid.