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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Purchasing a stoma cap that can cover and conceal the ileostomy when not in use indicates that the client is in the acceptance stage of grieving, as it shows that they have adapted to their new condition and are able to resume their normal activities and social interactions.

Choice B reason: Having their partner empty their pouch for them every morning indicates that the client is in the denial stage of grieving, as it shows that they are avoiding or rejecting their new condition and are dependent on others for their care.

Choice C reason: Being embarrassed by the odor that comes from their ileostomy indicates that the client is in the depression stage of grieving, as it shows that they have low self-esteem and negative feelings about their new condition and its impact on their quality of life.

Choice D reason: Missing going to their church meetings because of their ostomy indicates that the client is in the anger stage of grieving, as it shows that they have resentment and frustration about their new condition and its interference with their previous routines and values.

A. Weight loss B. Fatigue C. Dysuria D. Elevated temperature

Correct Answer is D

Explanation

Choice A: This is incorrect because weight loss is not the highest priority finding for the nurse to report to the provider. Weight loss can be a common symptom of leukemia due to decreased appetite, increased metabolism, or malabsorption.

Choice B: This is incorrect because fatigue is not the highest priority finding for the nurse to report to the provider. Fatigue can be a common symptom of leukemia due to anemia, infection, or poor nutrition.

Choice C: This is incorrect because dysuria is not the highest priority finding for the nurse to report to the provider. Dysuria can indicate a urinary tract infection, which can be treated with antibiotics and fluids.

Choice D: This is correct because elevated temperature is the highest priority finding for the nurse to report to the provider. Elevated temperature can indicate a serious infection, which can be life-threatening for a client who has leukemia and a compromised immune system.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is collecting data from a client who is 1 month postoperative following an ileostomy. Which of the following statements by the client indicates the client is in the acceptance stage of grieving?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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