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 C

Explanation

A. While consulting the palliative care team is appropriate for end-of-life care, it is essential first to clarify the client's understanding and wishes regarding "heroic measures" to ensure her preferences are fully understood and respected.
B. Setting up a family conference is important for discussing the client’s wishes with her loved ones, but this should occur after the nurse understands the client's specific desires.
C. The nurse should first discuss with the client what she means by "heroic measures" to ensure that her wishes are clearly understood. This conversation is essential to ensure that any subsequent actions, such as obtaining a DNR order, align with the client’s specific wishes.
D. A DNR prescription is an important step in respecting the client's wishes, but it should only be obtained after confirming exactly what the client means by "heroic measures" and ensuring that she fully understands the implications of a DNR order.

A. Notify the information services department of the situation. B. Print electronic medical record (EMR) from the backup server. C. Identify information as a late entry in the record. D. Wait for notification that the system has been rebooted.

Correct Answer is A

Explanation

A. The first priority is to notify the information services department to address the technical issue with the computer system. This ensures that the problem is being handled and allows the nurse to focus on immediate patient care needs.
B. Printing the EMR from the backup server is not possible until the issue with the computer system is resolved. Immediate reporting to IT is necessary to address the technical problem first.
C. Identifying information as a late entry is premature and not the immediate priority. Ensuring the functionality of the electronic system is crucial before making manual records.
D. Waiting for the system to reboot does not address the immediate need for technical support and may delay patient care.

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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.

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Naxlex Comprehensive Predictor Exams

An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first?

Correct Answer is C

Explanation

While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?

Correct Answer is A

Explanation

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

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The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

A bedfast female client awakens during the night, reporting to the nurse that she is "uncomfortable." What action should the nurse implement first?

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.

The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. 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.