The nurse is preparing to provide wound care for a group of clients in the outpatient setting. The nurse understands which action is considered best practice when providing wound care?

Complete every dressing change using sterile technique.

Quickly remove any tape from the client's skin before beginning.

Gather supplies before beginning wound care procedures.

Document wound care at the end of the shift to save time.

Answer and Explanation

The Correct Answer is C

A. Complete every dressing change using sterile technique: Not all wounds require sterile technique; many chronic or noninvasive wounds are appropriately managed with clean technique. Using sterile technique unnecessarily increases cost and does not improve outcomes for all wound types. Best practice involves selecting technique based on wound type and setting.

B. Quickly remove any tape from the client's skin before beginning: Rapid tape removal increases the risk of skin tears, especially in older adults or those with fragile skin. Proper technique involves supporting the skin and removing tape slowly in the direction of hair growth.

C. Gather supplies before beginning wound care procedures: Organizing all necessary supplies in advance maintains asepsis, prevents interruption of the procedure, and reduces the risk of contamination. This approach promotes efficiency, client safety, and adherence to infection prevention principles. Preparation is a foundational element of best practice nursing care.

D. Document wound care at the end of the shift to save time: Delayed documentation increases the risk of omitted or inaccurate information regarding wound appearance and interventions. Wound care findings should be documented promptly after completion to ensure accuracy and continuity of care. Timely documentation supports clinical decision-making.

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Correct Answer is B

Explanation

A. Kussmaul respirations: These are deep, rapid, and labored respirations typically associated with metabolic acidosis, such as diabetic ketoacidosis. They do not include alternating periods of apnea and hyperventilation, so they do not match the described pattern.

B. Cheyne-Stokes respirations: This breathing pattern is characterized by cyclic periods of increasing and decreasing depth of respiration, followed by temporary apnea. It commonly occurs in clients with advanced heart failure, neurological injury, or nearing end-of-life, making it consistent with hospice clients exhibiting irregular breathing.

C. Agonal breathing: Agonal respirations are irregular, gasping breaths often seen in severe hypoxia or near death. They are typically ineffective for gas exchange and not part of a regular cyclical pattern.

D. Biot's respirations: Biot’s respirations consist of groups of quick, shallow breaths followed by irregular pauses. They are usually associated with increased intracranial pressure or medullary damage rather than end-of-life breathing patterns.

A. By focusing on medical diagnoses B. By examining interrelationships C. By following a linear approach D. By reducing assessment time

Correct Answer is B

Explanation

A. By focusing on medical diagnoses: Limiting a concept map to medical diagnoses restricts the nurse’s perspective and does not fully engage critical thinking. Concept maps integrate multiple aspects of patient care, including psychosocial, physiological, and nursing considerations, rather than focusing solely on diagnoses.

B. By examining interrelationships: Concept maps visually display the connections among patient problems, interventions, and outcomes, helping nurses identify patterns and prioritize care. Examining these interrelationships promotes deeper understanding, clinical reasoning, and the ability to anticipate complications. It enhances critical thinking and holistic patient care.

C. By following a linear approach: Concept maps are nonlinear tools that allow flexible exploration of complex patient situations. A strictly linear approach limits the ability to see connections and interactions, reducing opportunities for critical analysis.

D. By reducing assessment time: Concept maps do not shorten assessment but instead organize and synthesize data. Their value lies in improving understanding and decision-making rather than accelerating the assessment process.

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The nurse is preparing to provide wound care for a group of clients in the outpatient setting. The nurse understands which action is considered best practice when providing wound care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse cares for a hospice client who exhibits irregular breathing patterns, alternating between periods of apnea and hyperventilation. What breathing pattern should the nurse document?

Correct Answer is B

Explanation

How does a concept map enhance critical thinking in nursing practice?

Correct Answer is B

Explanation

Which statement(s) uphold the principles of sterility? Select all that apply.

The nurse provided discharge teaching to the client's family on preventing pressure injuries at home. Which statement made by the family member indicates a need for further instruction?

Review the electronic health record, Based on these findings, which vital sign should the nurse address first?

The nurse is watching a new nurse ventilate a client using a bag-valve mask with capnography capabilities. The nurse notices that the client's PaCO2 level is 30 mm Hg. How should the nurse interpret this finding?

A nurse is caring for a client with measles. Which isolation precautions should the nurse implement?

The nurse has provided education to a client and their family member about how to change wound dressings. Which client statement indicates the need for additional teaching?

The nurse observes a visitor of a client with meningitis. Which finding should concern the nurse?

The nurse cares for a client with a wound. What assessment(s) should the nurse complete during the inspection phase of the wound assessment? Select all that apply.