The nurse on the progressive care unit is preparing to perform a sterile wet to dry dressing change on a client with a sacral pressure ulcer. The nurse notes that the sterile saline at the bedside is marked as opened 48 hours ago. What is the nurse’s priority action?

Discard the bottle of saline and obtain a new bottle

Lip the battle of saline over the trash before pouring into the field

Pour the saline at least 6 inches above the sterile field

Be sure the label is facing the palm before pouring

Answer and Explanation

The Correct Answer is A

A. Discard the bottle of saline and obtain a new bottle:

Sterility is crucial when performing a sterile procedure. If the saline solution has been opened for 48 hours, it may no longer be considered sterile. The nurse's priority is to use a fresh, sterile bottle of saline to ensure aseptic technique during the dressing change.

B. Lip the bottle of saline over the trash before pouring into the field:

Lipping the bottle over the trash is not a recommended practice. Pouring the saline over a sterile field is the appropriate way to maintain the sterility of the solution.

C. Pour the saline at least 6 inches above the sterile field:

While pouring from a height can help generate a flow without contamination, the priority in this situation is to address the sterility of the saline. It's crucial to start with a new, unopened bottle.

D. Be sure the label is facing the palm before pouring:

The orientation of the label is not the primary concern in this scenario. The primary concern is the sterility of the saline solution.

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Correct Answer is A

Explanation

A. Allow the patient to relax and then recheck the patient’s B/P in 5 minutes:

The initial elevated blood pressure reading could be influenced by the patient's anxiety about visiting the doctor. Allowing the patient to relax and rechecking the blood pressure after a few minutes may provide a more accurate reading.

B. Document the elevated blood pressure and notify the physician immediately:

It is premature to immediately notify the physician based on a single elevated blood pressure reading. Reassessing after the patient has had time to relax is a reasonable approach before taking further action.

C. Begin education related to hypertension (high blood pressure):

While patient education is important, addressing the patient's anxiety and obtaining accurate blood pressure readings should be the initial focus.

D. Schedule the patient for follow-up visits for measurement and monitoring of the patient’s blood pressure:

Scheduling follow-up visits may be necessary based on subsequent assessments, but the immediate concern is to recheck the blood pressure after allowing the patient to relax.

A. Wash the client’s face. B. Remove dentures. C. Apply lubricant. D. Don gloves.

Correct Answer is D

Explanation

A. Wash the client’s face:

While washing the client's face might be part of general care, when specifically providing oral care for a client with dentures, the first step should be to don gloves to ensure infection control and safety.

B. Remove dentures:

Removing dentures may be a step in the oral care process, but it should come after donning gloves to maintain proper infection control measures.

C. Apply lubricant:

Applying lubricant might be necessary, especially if the client experiences dryness or discomfort, but it should follow the step of donning gloves.

D. Don gloves:

This is the first action because it is crucial to wear gloves before handling a client's dentures or engaging in any oral care procedures. Gloves protect both the nurse and the client from potential infections and ensure proper hygiene during care.

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The nurse on the progressive care unit is preparing to perform a sterile wet to dry dressing change on a client with a sacral pressure ulcer. The nurse notes that the sterile saline at the bedside is marked as opened 48 hours ago. What is the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is providing oral care to a client with dentures. What action would the nurse do first?

Correct Answer is D

Explanation

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