A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

Uses normal saline to irrigate the wound.

Cleans from less soiled to more soiled areas.

Opens a sterile package towards the body.

Places soiled dressing in a plastic bag.

Answer and Explanation

The Correct Answer is C

Choice A reason: Using normal saline to irrigate the wound is a correct practice and does not indicate a need for additional teaching. Normal saline is isotonic and is commonly used for wound irrigation because it does not interfere with the natural healing process.

Choice B reason: Cleaning from less soiled to more soiled areas is also a correct technique to prevent contamination of cleaner areas. This method helps to reduce the risk of infection and is a standard practice in wound care.

Choice C reason: Opening a sterile package towards the body is incorrect and indicates that additional teaching is needed. When opening a sterile package, it should be opened away from the body to maintain the sterility of the contents and prevent contamination.

Choice D reason: Placing soiled dressing in a plastic bag is a proper disposal method and does not indicate a need for additional teaching. It is important to properly dispose of soiled dressings to prevent the spread of infection.

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Correct Answer is C

Explanation

Choice A reason: While a medication reference guide is useful, it does not replace the need for clarification from the prescribing healthcare provider regarding dosage discrepancies.

Choice B reason: The nursing unit charge nurse can be a resource, but the prescriber should be the first contact for medication orders.

Choice C reason: The healthcare provider who prescribed the medication is the most appropriate resource to clarify and potentially correct the dosage of the oral antibiotic.

Choice D reason: The hospital pharmacist is a valuable resource for medication information and can be consulted, but the prescriber should first be contacted to address the discrepancy in dosages.

A. Modify the nursing interventions to achieve the client's goals. B. Determine if the expected outcomes were realistic. C. Obtain current client data to compare with expected outcomes. D. Review related professional standards of care.

Correct Answer is C

Explanation

Choice A reason: Modifying nursing interventions is a step that may be necessary after evaluating the effectiveness of care, but it is not the immediate next action after reviewing the expected outcomes.

Choice B reason: Determining if the expected outcomes were realistic is part of the evaluation process, but it requires current data to make an informed decision.

Choice C reason: Obtaining current client data is essential to compare with the expected outcomes and determine if the goals of care are being met.

Choice D reason: Reviewing related professional standards of care is important for ensuring quality care, but it is not the direct next step in evaluating the effectiveness of the client's nursing care.

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A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

Correct Answer is C

Explanation

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume? Select all that apply.

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Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.