A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?

Choice A Reason:
Preparing the sterile dressing supplies 30 min before the dressing change is correct. While it's crucial to have all supplies ready before starting the procedure, preparing them 30 minutes in advance might not align with the principles of maintaining sterility. It's generally best to prepare sterile supplies just before the procedure to minimize the risk of contamination.
Choice B Reason:
Don sterile gloves before removing the dressing is incorrect. Sterile gloves should indeed be worn during the dressing change, but they should be put on after removing the old dressing. This ensures that the clean gloves don't touch potentially contaminated surfaces during the removal of the old dressing.
Choice C Reason:
Disinfect the wound bed with alcohol before applying tape is incorrect. Using alcohol to disinfect the wound bed is not recommended as it can cause tissue irritation and delay wound healing. Sterile saline or another wound cleansing solution prescribed for wound care would be more appropriate to clean the wound bed. Additionally, applying tape directly to the wound is generally avoided to prevent further damage to the fragile tissues of a pressure ulcer.
Choice D Reason:
Offering the client pain medication before the procedure is correct. Providing pain medication before the procedure ensures the client's comfort and helps manage any discomfort or pain associated with the dressing change, particularly when dealing with a stage III pressure ulcer, which can be quite sensitive.

Choice A Reason:
Polyuria is incorrect. Peritonitis doesn’t directly influence urine output. Polyuria (increased urine production) is more commonly associated with conditions affecting the kidneys or diabetes mellitus rather than peritonitis.
Choice B Reason:
Peripheral edema is incorrect. Peritonitis typically involves abdominal symptoms and signs rather than peripheral issues like edema. Edema can be related to heart, kidney, or circulatory system problems, but it's not a typical manifestation of peritonitis.
Choice C Reason:
Decreased respirations is incorrect. Peritonitis can cause pain and discomfort, which might affect the depth of breathing or result in shallow breathing due to guarding against abdominal pain. However, decreased respirations as a specific finding wouldn't commonly be expected in peritonitis. Pain might cause shallow breathing, but it wouldn't lead to a consistent decrease in respiratory rate.
Choice D Reason:
Absent bowel sounds is correct. Peritonitis is an inflammation of the peritoneum, the lining of the abdominal cavity. This condition often leads to the loss or significant reduction of bowel sounds due to the irritation and inflammation of the abdominal structures.