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
The flu shot provides protection for about one year. It is recommended to receive the flu shot annually for continued protection, especially as flu strains can vary each year.
Choice B rationale
The hepatitis B vaccine does not require annual administration. It is typically given in a series of shots over a few months and provides long-term protection.
Choice C rationale
Performing a breast self-exam a week after each menstrual period is ideal because hormonal changes that cause breast tissue to be tender or lumpy will be minimal, making it easier to detect any unusual changes.
Choice D rationale
Testicular self-exams are recommended to be done monthly, not every 6 months. Regular monthly exams help in early detection of any changes or abnormalities.
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. .
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