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 B
Explanation
Choice A rationale
Helicobacter pylori infection is associated with gastrointestinal conditions like peptic ulcers and gastritis, not with inner ear inflammation.
Choice B rationale
Viral respiratory infections can spread to the middle ear through the Eustachian tube, potentially leading to inflammation and infection of the inner ear (otitis media).
Choice C rationale
A tumor pressing on the pituitary gland can cause hormonal imbalances but is not directly related to inner ear inflammation.
Choice D rationale
Ampicillin, an antibiotic, is used to treat bacterial infections but does not inherently increase the risk of inner ear inflammation.
Correct Answer is A
Explanation
Choice A rationale
A changed mental status is a common sign of a urinary tract infection, especially in older adults, due to the effects of the infection on the central nervous system.
Choice B rationale
WBC count 9,000/mm³ is within the normal range of 5,000 to 10,000/mm³ and does not indicate an infection on its own.
Choice C rationale
Diminished reflexes are not typically associated with bladder infections and are not a reliable indicator.
Choice D rationale
A temperature of 37.3°C (99.1°F) is within the normal range and does not necessarily indicate a bladder infection.
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