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?
Don sterile gloves before removing the dressing.
Offer the client pain medication before the procedure.
Prepare the sterile dressing supplies 30 min before the dressing change.
Disinfect the wound bed with alcohol before applying tape.
The Correct Answer is B
Choice A: This is incorrect. The nurse should don clean gloves before removing the dressing, and then change to sterile gloves before applying the new dressing.
Choice B: This is correct. The nurse should offer the client pain medication before the procedure, as changing a dressing for a stage III pressure ulcer can be very painful.
Choice C: This is incorrect. The nurse should prepare the sterile dressing supplies just before the dressing change, not 30 min before, to prevent contamination.
Choice D: This is incorrect. The nurse should not disinfect the wound bed with alcohol, as this can damage the healthy tissue and delay healing. The nurse should use a saline solution or an antiseptic solution as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Applying an SPF 30 sunscreen before gardening is an appropriate statement, as it indicates that the client understands the importance of protecting their skin from sun exposure, which can trigger or worsen lupus flare-ups and cause skin rashes or lesions.
Choice B reason: Cleansing reddened areas of their face with an astringent is not an appropriate statement, as it indicates that the client does not understand that astringents can irritate or dry out their skin and aggravate their condition. The client should use mild soap and water or moisturizing cleanser to wash their face gently.
Choice C reason: Gently patting their skin dry after bathing is an appropriate statement, as it indicates that the client understands how to avoid rubbing or scratching their skin, which can cause injury or infection and delay healing.
Choice D reason: Applying lotion to their skin twice daily is an appropriate statement, as it indicates that the client understands how to keep their skin hydrated and prevent dryness or cracking that can increase their risk of infection or inflammation.
Choice E reason: Limiting time on tanning beds to 10 minutes is not an appropriate statement, as it indicates that the client does not understand that tanning beds emit ultraviolet rays that can harm their skin and worsen their lupus symptoms. The client should avoid tanning beds altogether and wear protective clothing and sunglasses when outdoors.
Correct Answer is A
Explanation
Choice A reason: The nurse should contact the provider to clarify the prescription because applying heat to an area with impaired sensation can cause burns or tissue damage. The nurse should also educate the client about the risks of using heat therapy and alternative methods to relieve pain.
Choice B reason: The Semmes Weinstein monofilament test is used to assess the sensation of light touch in clients with peripheral neuropathy. The nurse should perform this test before applying any intervention that could affect the skin integrity, such as heat, cold, or compression.
Choice C reason: Observing the skin 10 min after the start of treatment is not sufficient to prevent complications from heat therapy. The nurse should monitor the skin continuously and check for signs of redness, blisters, or burns.
Choice D reason: Applying the heating pad as prescribed by the provider is not appropriate for a client with diabetic neuropathy of the lower extremities. Heat can increase blood flow and inflammation in the affected area, which can worsen the condition and increase the risk of infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today