A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

Uses normal saline to irrigate the wound.

Cleans from less soiled to more soiled areas.

Opens a sterile package towards the body.

Places soiled dressing in a plastic bag.

Answer and Explanation

The Correct Answer is C

Choice A reason: Using normal saline to irrigate the wound is a correct practice and does not indicate a need for additional teaching. Normal saline is isotonic and is commonly used for wound irrigation because it does not interfere with the natural healing process.

Choice B reason: Cleaning from less soiled to more soiled areas is also a correct technique to prevent contamination of cleaner areas. This method helps to reduce the risk of infection and is a standard practice in wound care.

Choice C reason: Opening a sterile package towards the body is incorrect and indicates that additional teaching is needed. When opening a sterile package, it should be opened away from the body to maintain the sterility of the contents and prevent contamination.

Choice D reason: Placing soiled dressing in a plastic bag is a proper disposal method and does not indicate a need for additional teaching. It is important to properly dispose of soiled dressings to prevent the spread of infection.

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Correct Answer is C

Explanation

Choice A reason: Reducing the amount of pressure may not be effective if the pulse is weak or absent; other methods may be needed to assess circulation.

Choice B reason: Documentation is important, but it should be done after all attempts to assess the pulse have been made.

Choice C reason: Using a Doppler stethoscope is a suitable next step when a pulse is not palpable, as it can detect weaker pulses not felt by palpation.

Choice D reason: Palpating the site on the inner side of the ankle below the medial malleolus assesses the posterior tibial pulse, not the dorsalis pedis pulse.

A. Complete an admission assessment. B. Access a central venous line. C. Reinforce discharge teaching. D. Initiate blood product infusions.

Correct Answer is C

Explanation

Choice A reason: Completing an admission assessment is typically the responsibility of a registered nurse (RN) due to the comprehensive nature of the assessment.

Choice B reason: Accessing a central venous line is usually within the scope of practice of an RN, not a PN, due to the complexity and potential complications associated with central lines.

Choice C reason: Reinforcing discharge teaching is an appropriate task for a PN, as it involves reviewing and ensuring the client understands the instructions already provided by the RN or healthcare provider.

Choice D reason: Initiating blood product infusions is generally the responsibility of an RN because of the critical nature of the task and the potential for adverse reactions.

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A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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