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
Having clear liquids up to 3 hours before the procedure is incorrect. Clients are generally advised to be NPO (nothing by mouth) for a certain period before a bronchoscopy to prevent aspiration.
Choice B rationale
Eating as soon as the procedure is completed is incorrect. Clients need to wait until their gag reflex has returned before eating or drinking to prevent choking or aspiration.
Choice C rationale
Blood-tinged sputum after the procedure is an expected finding. Bronchoscopy can cause minor irritation and bleeding in the airways, leading to blood-tinged sputum.
Choice D rationale
Receiving an injection of radioactive material prior to the procedure is incorrect. This statement confuses bronchoscopy with other diagnostic tests such as a PET scan. Bronchoscopy involves direct visualization of the airways using a bronchoscope. .
Correct Answer is A
Explanation
Choice A rationale
Recent exposure to tuberculosis is the priority for the nurse to address because tuberculosis is a contagious and potentially serious infectious disease. Addressing this first helps prevent the spread of infection to other clients and healthcare staff.
Choice B rationale
While a history of generalized anxiety disorder is important, it is not the immediate priority compared to a contagious disease like tuberculosis. Anxiety can be managed with ongoing care and support.
Choice C rationale
Nocturia is a condition characterized by frequent urination at night and can indicate underlying health issues, but it is not an immediate priority compared to tuberculosis exposure.
Choice D rationale
Periodic migraine headaches can be debilitating and require management, but they do not pose an immediate risk to others like tuberculosis exposure does.
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