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The nurse is caring for a client in isolation who requires wound care. The nurse should prepare to enter the room by performing these actions in which order? (Arrange with the first step on top and the last step at the bottom.)

Don gloves.

Apply a surgical mask.

Put on an isolation gown.

Wash hands.

Answer and Explanation

The Correct Answer is D,C,B,A

Correct order: D C B A

Washing hands is the first step before any PPE is applied to ensure cleanliness and prevent the introduction of pathogens.
Putting on the isolation gown is the next step, as it protects the nurse's clothing from exposure to potentially infectious materials.
Applying a surgical mask is the next step to protect the nurse from airborne or droplet transmission.
Donning gloves is the final step, as gloves should be put on last to protect the hands while providing direct care, especially when dealing with wound care.

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Correct Answer is C

Explanation

A. After each instruction, ask if the client understands is not the most reliable method because the client may answer affirmatively out of politeness or lack of comprehension.

B. Provide written instructions in the client's native language is helpful as a supplementary teaching tool but does not evaluate the client's understanding or ability to perform wound care.

C. Have the client demonstrate prescribed wound care is the most effective method because it allows the nurse to directly observe the client’s technique and understanding, ensuring they can perform the task correctly at home.

D. Have an interpreter repeat the wound care instructions ensures accurate communication but does not assess whether the client can perform the care independently.

A. Warm, dry skin with a fever of 100.0° F (37.8° C). B. 4+ pitting edema of both lower extremities. C. A Braden risk assessment scale rating score of ten. D. Hypoactive bowel sounds with infrequent bowel movements.

Correct Answer is C

Explanation

A. Warm, dry skin with a fever of 100.0° F (37.8° C) is not directly related to the need for frequent turning. A fever and warm, dry skin may indicate an infection or another underlying condition, but it does not prioritize the need for turning in the context of pressure injury prevention.

B. 4+ pitting edema of both lower extremities may indicate fluid retention, but it is not as directly related to the risk of developing pressure injuries. Although edema can impact skin integrity, the Braden scale score is a more reliable indicator for turning schedules to prevent pressure ulcers.

C. A Braden risk assessment scale rating score of ten is the most important factor in determining the turning schedule. A score of ten indicates a high risk for developing pressure ulcers, which is directly related to the need for frequent repositioning to relieve pressure and prevent skin breakdown.

D. Hypoactive bowel sounds with infrequent bowel movements may be a concern for gastrointestinal function, but it does not directly affect the turning schedule. The Braden scale score is a better indicator for deciding how often the client needs to be turned to prevent pressure injuries.

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The nurse is caring for a client in isolation who requires wound care. The nurse should prepare to enter the room by performing these actions in which order? (Arrange with the first step on top and the last step at the bottom.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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