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 A
Explanation
Choice A rationale
Aligning the client's joints with the joints on the CPM device frame ensures proper movement and prevents injury or discomfort. Correct alignment is crucial for effective therapy and to avoid strain on the joints.
Choice B rationale
High-Fowler's position is typically used for respiratory issues and does not align with the use of a CPM device for knee arthroplasty. Proper positioning is essential for the device's function.
Choice C rationale
Using a thick pillow to pad the CPM device could interfere with the device's movement and efficacy. Proper padding should ensure comfort without hindering the machine's operation.
Choice D rationale
Setting the degree of flexion and extension as tolerated by the client is important, but it should be done under medical guidance to ensure therapeutic benefits and avoid injury. Alignment is the primary concern.
Correct Answer is ["A","C"]
Explanation
Choice A rationale: Allergy to penicillin can be a contraindication for administering cefazolin because of potential cross-reactivity between penicillins and cephalosporins. This client’s documented allergy to penicillin with symptoms of rash and throat swelling is significant and raises concern for a potential allergic reaction to cefazolin.
Choice B rationale: Elevated WBC count indicates an ongoing infection or inflammation, which is not a contraindication for cefazolin. Instead, it suggests the need for an antibiotic like cefazolin to manage the infection.
Choice C rationale: Prescription for furosemide is relevant because combining cephalosporins like cefazolin with diuretics like furosemide can increase the risk of nephrotoxicity. It’s important to consider the client’s renal function and monitor for potential kidney damage.
Choice D rationale: Fever >38.3°C is an indication for antibiotic therapy, not a contraindication. The elevated temperature suggests an infection that needs to be treated, making cefazolin appropriate in this context.
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