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Exhibits

The practical nurse (PN) is preparing to change the turban dressing.

For each intervention, click to indicate whether it is indicated or not indicated for the dressing change. Each row must have one

A.

Clean the site using sterile gauze and sterile water.

B.

Place client in a private room.

C.

Avoid hand sanitizer after the procedure.

D.

Place the soiled dressing in a red biohazard bag.

E.

Use sterile gloves to remove

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

  1. Clean the site using sterile gauze and sterile water.
    • Indicated: The turban dressing should be changed using sterile techniques to prevent infection and ensure proper wound care.
  2. Place client in a private room.
    • Not Indicated: The client is already on contact precautions for MRSA, so the private room is a general requirement and not a specific intervention for the dressing change.
  3. Avoid hand sanitizer after the procedure.
    • Not Indicated: Hand sanitizer is typically used before and after procedures. For MRSA contact precautions, hand hygiene is critical, and proper hand washing or using hand sanitizer is recommended after the procedure.
  4. Place the soiled dressing in a red biohazard bag.
    • Indicated: The soiled dressing is considered contaminated and should be disposed of in a red biohazard bag to prevent the spread of infection.
  5. Use sterile gloves to remove the old dressing.
    • Indicated: Sterile gloves are required for removing and replacing the dressing to maintain a sterile field and prevent infection.


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Related Questions

Correct Answer is B

Explanation

A. Acquiring coping skills is important, but the immediate focus for discharge planning is on practical goals related to managing daily activities and maintaining independence rather than on long-term psychological coping.
B. Conserve energy is the most important goal for a client with rheumatoid arthritis preparing for discharge. Managing energy effectively helps clients cope with fatigue and pain, which are common challenges in daily life with rheumatoid arthritis.
C. Adapting self-care skills is also important but is a broader goal that includes conserving energy as a component. Effective energy management is a key aspect of self-care for clients with rheumatoid arthritis.
D. Improving body image is a valid goal but is not the most urgent concern for discharge planning. The primary focus should be on practical aspects of managing rheumatoid arthritis in daily life.

Correct Answer is B

Explanation

A. Documenting the client's loss of memory is important for ongoing assessment, but it is not the immediate action to take when the client is confused about the day of the week.
B. Reminding the client of the day of the week is a direct intervention to help orient the client, which is a primary approach for managing acute confusion or disorientation.
C. Notifying the family of the change in the client’s condition may be necessary if confusion persists or worsens, but initial steps should focus on immediate management of the confusion.
D. Encouraging the client to rest is a general supportive action but does not address the specific issue of confusion about the day of the week.

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