A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?
Adhesive tape
Tongue depressor
Syringe
Cotton-tipped applicator
The Correct Answer is D
Choice A Reason:
Adhesive tape is incorrect. Adhesive tape is commonly used for securing dressings or medical devices, but it may not be the primary supply needed for managing a stage 4 pressure injury. Wound care for a stage 4 pressure injury often involves specialized dressings, cleansing solutions, and applicators rather than adhesive tape alone.
Choice B Reason:
Tongue depressor is incorrect. A tongue depressor is typically used for oral examinations or to apply topical treatments to the mouth. It's not a standard supply for managing a stage 4 pressure injury, which requires specific wound care supplies designed for wound cleaning and dressing application.
Choice C Reason:
Syringe is incorrect. While syringes are versatile tools used in various medical procedures, in the context of managing a stage 4 pressure injury, their primary use might be for administering medications or irrigation solutions rather than being the essential supply for wound care in this specific instance.
For a client with a stage 4 pressure injury, the nurse should obtain supplies that are suitable for wound care. Among the options provided, the most appropriate supply is:
Choice D Reason:
Cotton-tipped applicator is correct. A cotton-tipped applicator can be used for wound cleaning and dressing application for a stage 4 pressure injury. It allows for gentle cleaning of the wound and application of topical treatments while minimizing trauma to the wound area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.
Choice B Reason:
Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.
Choice C Reason:
The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.
Choice D Reason:
Injecting air into the ampule prior to drawing the medication into a syringe is incorrect. This action is not typically necessary when withdrawing medication from an ampule. Some medications may require air to equalize pressure, but it's crucial to follow specific guidelines for each medication. In most cases, creating positive pressure by injecting air into the ampule is not recommended, as it could affect the stability or integrity of the medication.
Correct Answer is A
Explanation
Choice A Reason:
A client who has ulcerative colitis is correct. Ulcerative colitis, a type of inflammatory bowel disease (IBD), involves chronic inflammation and ulceration in the colon and rectum. This condition often results in bleeding from the inflamed mucosa, leading to the presence of blood in the stool that can be detected by a fecal occult blood test.
Choice B Reason:
A client who has stomatitis is incorrect. Stomatitis refers to inflammation in the mouth and does not typically cause bleeding in the gastrointestinal tract, which is what the fecal occult blood test detects. Stomatitis involves oral lesions or sores but does not directly impact stool blood content.
Choice C Reason:
A client who uses laxatives is incorrect. Laxative use does not necessarily cause bleeding in the gastrointestinal tract. While some laxatives can potentially irritate the intestinal lining, leading to minor bleeding in some cases, the presence of blood in the stool due to laxative use is less common compared to conditions like ulcerative colitis, where chronic inflammation and ulceration lead to significant bleeding.
Choice D Reason:
A client who has cholecystitis is incorrect. Cholecystitis is inflammation of the gallbladder and does not directly involve bleeding in the gastrointestinal tract. It typically presents with symptoms related to gallbladder inflammation such as abdominal pain, nausea, and vomiting, rather than causing bleeding that would be detected by a fecal occult blood test.
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