Exhibits

The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.

Gather materials to change soiled items only

Thoroughly clean wound using normal saline prior to redressing

Place sterile gauze directly on wound bed

Apply sterile gloves prior to changing

Apply sterile foam dressing over wound bed

Maintain clean medical asepsis

Answer and Explanation

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

Gather materials to change soiled items only: Not indicated. The nurse should gather all necessary materials for the entire wound care procedure, not just for changing soiled items, to ensure the dressing change is performed efficiently and effectively.
Thoroughly clean wound using normal saline prior to redressing: Indicated. Proper wound cleaning with normal saline helps remove debris and reduce bacterial load, preparing the wound for the application of new dressings.
Place sterile gauze directly on wound bed: Not indicated. The wound care order specifies the use of anasept gel covered with foam dressing. Sterile gauze is not the appropriate dressing in this scenario.
Apply sterile gloves prior to changing: Indicated. Sterile gloves are necessary to maintain sterility and prevent infection during the dressing change procedure.
Apply sterile foam dressing over wound bed: Indicated. The orders specify the use of a foam dressing after applying anasept gel, which provides the necessary coverage and protection for the wound.
Maintain clean medical asepsis: Not indicated. While maintaining a clean environment is important, sterile technique (rather than clean medical asepsis) is required for this dressing change to prevent infection and promote healing in the wound bed.

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Correct Answer is B

Explanation

A. While applying a barrier ointment is important for preventing further skin breakdown, it does not address the immediate need to assess the severity of existing damage.
B. Determining the size and depth of skin breakdown is crucial for assessing the severity of the pressure injury and planning appropriate treatment. Accurate assessment helps in selecting the right interventions and monitoring the progression of the wound.
C. Completing a functional assessment of the client's self-care abilities is important for overall care planning but should follow the initial assessment of the skin breakdown to ensure immediate needs are addressed.
D. Establishing a toileting schedule is a preventive measure for future incontinence but does not address the current skin breakdown that needs immediate assessment and treatment.

A. Instruct the client in use of the prescribed patient-controlled analgesia (PCA) pump. B. Assist the client in assuming a lateral recumbent position for comfort. C. Initiate continuous passive motion (CPM) to relieve muscle spasms. D. Apply ice to the incision for twenty minutes prior to joint flexion exercises.

Correct Answer is A

Explanation

A. Instructing the client in the use of the PCA pump directly addresses the severe pain by allowing the client to self-administer analgesia as needed, which provides immediate relief and is crucial for effective pain management post-surgery.
B. Assisting the client in changing positions may offer temporary relief but does not address the underlying pain, which should be managed primarily through medication.
C. Initiating CPM is not an appropriate first step for managing severe pain. CPM is used for improving joint mobility and should only be considered after effective pain management is established.
D. Applying ice might provide some temporary relief, but it is not a substitute for effective pain control through medication. Addressing the pain with PCA is the priority.

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Exhibits The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

Correct Answer is B

Explanation

Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

Correct Answer is A

Explanation

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)

The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

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A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Exhibits The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.

During the prodromal stage of an infection, which is the priority nursing intervention?

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

Exhibits

The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.