A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?
Determine the client's pain level.
Irrigate the wound with 0.9% sodium chloride irrigation.
Apply skin preparation to wound edges.
Don sterile gloves.
The Correct Answer is A
A.
A. Assessing the client's pain level is the first step to ensure appropriate pain management during the procedure.
B. Irrigating the wound comes after assessing the client's pain level and preparing the wound for the dressing change.
C. Applying skin preparation to wound edges is part of the preparation process but should come after assessing the client's pain level.
D. Donning sterile gloves is necessary for the procedure but should come after assessing the client's pain level.
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Related Questions
Correct Answer is D
Explanation
A. The provider is not required to notify the client's employer about the admission to a mental health facility. This information is protected under confidentiality laws and regulations.
B. While the client may be strongly encouraged to take prescribed medications, they cannot be forced to do so without consent, especially if they are competent to make their own decisions.
C. Electroconvulsive therapy (ECT) typically requires informed consent from the patient or their legal representative, even in an involuntary admission scenario. Therefore, it is incorrect to state that ECT can be performed without consent.
D. If the client poses a risk of harm to themselves or others, the provider can prescribe restraints as a safety measure. This statement is correct and aligns with safety protocols in mental health facilities.
Correct Answer is C
Explanation
A. Decreased serum osmolarity: Fluid volume deficit typically leads to an increase in serum osmolarity due to concentration of solutes in the blood, not a decrease.
B. Decreased hematocrit: Dehydration causes hemoconcentration, leading to an increase in hematocrit, not a decrease.
C. Elevated blood urea nitrogen (BUN): Dehydration results in decreased renal perfusion and concentration of urea in the blood, leading to elevated BUN levels.
D. Lower urine specific gravity: Dehydration causes increased urine concentration, resulting in higher urine specific gravity, not lower.
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