The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action?
Continue changing the dressing
Open a new sterile dressing kit
Wash the client's hands
Restrain the client's hands
The Correct Answer is B
A. Continuing risks contamination and infection.
B. Opening a new sterile dressing kit is necessary because the sterility of the current kit has been compromised by the client's touch.
C. Washing the client’s hands is important but doesn’t restore sterility to the dressing kit.
D. Restraining without assessing safety or other options is not appropriate immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Discharge preparation involves teaching and planning, but ISBARR is not typically used.
B. Documentation uses standard medical record formats, not ISBARR.
C. ISBARR is designed for clear, structured communication between healthcare providers, especially during client handoffs like transferring from the emergency department to acute care.
D. Reporting to family uses a different communication style focused on support and explanation.
Correct Answer is B
Explanation
A. Using gentle patting motions is appropriate to protect fragile skin in older adults.
B. Using a large quantity of soap can dry and irritate the older adult’s skin; only a small amount of mild soap should be used.
C. Inspecting the feet is important for detecting issues like infections or pressure sores.
D. Testing water temperature ensures safety and prevents burns
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