The nurse plans care for a client with a wound. What action should the nurse incorporate into the client's care plan to minimize discomfort during wound care?

Disregard client facial grimacing during the procedure and continue quickly.

Administer pain medication at least 30 minutes before the dressing change.

Cleanse the wound with cold solution to help numb the area.

Remove the dressing quickly and without warning to reduce anxiety.

Answer and Explanation

The Correct Answer is B

A. Disregard client facial grimacing during the procedure and continue quickly: Facial grimacing is a nonverbal indicator of pain and should prompt reassessment rather than be ignored. Continuing without addressing discomfort can increase pain perception and anxiety. Client-centered care requires ongoing pain evaluation during wound care.

B. Administer pain medication at least 30 minutes before the dressing change: Pre-medicating allows analgesics sufficient time to reach therapeutic levels before the procedure. Adequate pain control reduces physiologic stress responses and improves tolerance of wound care. This intervention is a standard evidence-based approach to minimizing procedural pain.

C. Cleanse the wound with cold solution to help numb the area: Cold solutions can increase discomfort and cause vasoconstriction, which may impair local circulation and healing. Wound cleansing solutions are typically warmed to body temperature to enhance comfort. Cold application is not recommended for routine wound care.

D. Remove the dressing quickly and without warning to reduce anxiety: Sudden removal can increase pain and distress, particularly if the dressing adheres to the wound bed. Explaining the procedure and removing dressings slowly with appropriate moisture reduces tissue trauma. Clear communication supports comfort and trust during care.

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Correct Answer is C

Explanation

A. "Visitors can bring you a potted plant for your room.": Live plants can harbor mold and bacteria, which pose a serious infection risk for immunocompromised clients on neutropenic precautions. Soil and water in potted plants are common sources of pathogens. Plants are contraindicated in neutropenic client rooms.

B. "Visitors can bring you fresh fruit from the market.": Fresh fruits and vegetables may carry bacteria, fungi, or pesticides that can cause infections in clients with neutropenia. Even if washed, they are not considered safe. Raw or unprocessed produce is restricted to minimize infection risk.

C. "Visitors can bring you paper flower arrangements.": Artificial items such as paper flowers do not carry microbes and are safe for clients on neutropenic precautions. They allow for decorative gifts without increasing infection risk. This aligns with safety guidelines for immunocompromised individuals.

D. "Visitors can bring you your favorite raw vegetables.": Raw vegetables can harbor pathogens despite cleaning and present a high risk of infection. Clients with neutropenia are advised to avoid raw produce, including salads and uncooked vegetables. Only thoroughly cooked or processed foods are considered safe.

A. All visitors should wear hair and shoe covers. B. All visitors should wear a gown and gloves. C. All visitors should wear goggles and gloves. D. All visitors should wear an N95 mask and gown.

Correct Answer is B

Explanation

A. All visitors should wear hair and shoe covers: Hair and shoe covers are not part of standard contact precautions for MRSA. Transmission occurs primarily through direct contact with contaminated surfaces or wounds rather than hair or footwear. Routine use of these items does not reduce MRSA spread.

B. All visitors should wear a gown and gloves: MRSA requires contact precautions to prevent transmission via hands and clothing. Gowns protect clothing from contamination, and gloves reduce direct contact with infectious material. This practice is consistent with infection prevention guidelines for multidrug-resistant organisms.

C. All visitors should wear goggles and gloves: Eye protection is reserved for situations with a risk of splashing or spraying of body fluids. MRSA wound care does not typically pose this risk during routine contact. Goggles are not routinely indicated.

D. All visitors should wear an N95 mask and gown: N95 respirators are used for airborne pathogens such as tuberculosis, not contact-spread organisms like MRSA. Respiratory protection is unnecessary unless aerosol-generating procedures are involved.

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The nurse plans care for a client with a wound. What action should the nurse incorporate into the client's care plan to minimize discomfort during wound care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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