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 A
Explanation
A. Infection risk is the most relevant concern for an overweight client undergoing abdominal surgery. Excess adipose tissue can impair wound healing, increase the risk of dehiscence, and create an environment more prone to infection.
B. Altered body temperature is not commonly associated with being overweight in the surgical context.
C. Aspiration risk is more directly related to factors like sedation, anesthesia, or swallowing issues, not primarily to excess weight.
D. While there may be some increased risk of falls in overweight individuals, infection is the most immediate and surgery-specific concern for care planning in this context.
Correct Answer is C
Explanation
A. It’s important for clients to ask for pain medications, this is not a misconception.
B. Nurses are indeed there to help relieve pain, this is a correct belief.
C. Many clients mistakenly fear they will become addicted to pain medications, which is a common misconception.
D. Clients should not have to endure pain without help, this is a correct understanding.
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