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. While pain can motivate protective behaviors, it does not directly increase personal strength.
B. Acute pain is a subjective experience but serves an important biological purpose.
C. Acute pain is protective because it warns an individual of tissue damage or disease, prompting actions to avoid further harm and seek treatment.
D. Pain is subjective, not objective, and while it can aid diagnosis, its primary role is protective rather than diagnostic.
Correct Answer is D
Explanation
A. Decreasing the amount of fluids is not appropriate. Adequate fluid intake (2,000–3,000 mL/day) is essential to help fiber work effectively in promoting bowel regularity.
B. Both fruits and vegetables provide important sources of fiber and nutrients; omitting one would reduce the nutritional value of the diet.
C. High-fiber foods are beneficial for digestive health, especially when paired with adequate fluid intake, as in this case.
D. Nothing needs to be changed — the client’s diet is well-balanced with high-fiber foods, fruits, vegetables, and sufficient fluid intake, all of which help maintain healthy bowel function.
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