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.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Engaging the client in relaxation exercises may be helpful but should be considered after addressing potential physical causes of discomfort, such as positioning.
B. Offering to sit with the client is supportive, but the primary issue of physical discomfort should be addressed first.
C. Administering a PRN analgesic may be necessary if the discomfort persists, but repositioning the client is a less invasive intervention to try first.
D. Assisting the client to a different position is the first action the nurse should take. A change in position can often alleviate discomfort for bedfast clients and is a simple, non-invasive intervention.

A. Journaling B. Return demonstration. C. Role playing. D. Analogies.

Correct Answer is C

Explanation

A. Journaling can be helpful for self-reflection but does not provide the interactive, practice-oriented learning needed to improve communication skills in challenging situations.
B. Return demonstration is typically used for teaching physical tasks and skills, not for communication or interpersonal interactions.
C. Role-playing is the best instructional strategy in this scenario. It allows nursing staff to practice handling difficult conversations in a controlled environment, receive feedback, and build confidence in managing real-life situations involving angry family members.
D. Analogies can be useful for explaining concepts, but they do not provide the experiential learning needed to effectively respond to anger.

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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

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

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

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?

The nurse observes a colleague sharing computer credentials with a colleague who is struggling with access to the electronic health record (EHR). 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.

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?

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?

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?

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.