A nurse is preparing to perform a sterile dressing change for a client who has a stage III pressure ulcer.Which of the following actions should the nurse plan to take?
Disinfect the wound bed with alcohol before applying tape.
Prepare the sterile dressing supplies 30 min before the dressing change.
Don sterile gloves before removing the dressing.
Offer the client pain medication before the procedure.
The Correct Answer is D
Choice A rationale
Disinfecting the wound bed with alcohol can cause tissue damage and delay healing. The appropriate action is to clean the wound with a saline solution.
Choice B rationale
Preparing sterile dressing supplies 30 minutes before the procedure can compromise sterility. Supplies should be prepared immediately before use.
Choice C rationale
Sterile gloves are worn during the dressing change procedure, not for removing the old dressing. Clean gloves are appropriate for removing the old dressing.
Choice D rationale
Offering the client pain medication before the procedure can help manage pain and discomfort during the dressing change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Rotating the jejunostomy tube daily is not necessary and may cause unnecessary discomfort or complications.
Choice B rationale
Administering the feeding solution at a cold temperature can cause abdominal cramping and discomfort. It should be given at room temperature.
Choice C rationale
Elevating the head of the client's bed for 1 hour after feeding helps prevent aspiration, a serious complication of enteral feedings.
Choice D rationale
Flushing the tube with 90 mL of sterile water is excessive; the standard practice is to use 30-60 mL to clear the tube before and after feedings. .
Correct Answer is B
Explanation
Choice A rationale
Closing the doors can help contain the smoke, but it is not the first action. The priority is to activate the fire alarm to alert the fire department and initiate the building's emergency procedures.
Choice B rationale
Activating the fire alarm system ensures that all occupants are alerted to the fire, and the fire department is notified. This is the first step in managing a fire emergency.
Choice C rationale
Assisting the client to a nearby common area is important for their safety, but it should be done after activating the fire alarm.
Choice D rationale
Using a fire extinguisher may be necessary if the fire is small and contained, but the first priority is to alert others and get professional help on the way.
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