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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Place a hat on the client's head: Covering the head helps reduce heat loss, but it does not immediately stop ongoing heat loss from wet clothing in hypothermia. Head covering alone is insufficient in acute exposure.
B. Remove wet clothes, replacing them with dry ones: Wet clothing increases conductive and evaporative heat loss, accelerating hypothermia. Removing wet garments and replacing them with dry, insulated clothing or blankets immediately prevents further body heat loss and stabilizes core temperature. This is the highest priority initial action.
C. Provide hot liquids once the client is conscious: Warm fluids can support rewarming but are only safe after the client is alert and able to swallow. This intervention is secondary to removing wet clothing and insulating the body.
D. Place a warming blanket over the client: Warming blankets are effective for rewarming but work best after wet clothing is removed. Placing a blanket over wet clothing may trap cold and slow rewarming.
Correct Answer is A
Explanation
A. Obtain the client's apical heart rate: A radial pulse of 52 beats/minute is below the normal adult range (60–100 bpm), indicating bradycardia. Assessing the apical heart rate provides a more accurate measure of cardiac output and identifies potential discrepancies between central and peripheral pulses. This step is the immediate priority before further interventions.
B. Assess for a pulse deficit: Pulse deficit measurement compares apical and radial pulses to identify ineffective contractions, often in atrial fibrillation. This assessment is secondary and requires the apical pulse first.
C. Notify the healthcare provider: While notification may be necessary depending on findings, the nurse must first verify the heart rate and assess the client’s condition before contacting the provider. Immediate confirmation guides appropriate communication.
D. Review previous vital sign trends: Reviewing trends is useful to determine if bradycardia is new or chronic, but it does not replace the immediate need to accurately assess the current cardiac status. Immediate verification takes priority.
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