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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Starting with the most difficult questions can make the client uncomfortable and less likely to be open in the discussion.
Choice B reason: Beginning with less sensitive questions can help build rapport and make the client feel more comfortable discussing more intimate details later in the interview.
Choice C reason: Asking questions in a vague, non-specific format can lead to confusion and may not yield the necessary information.
Choice D reason: Sharing personal values is not appropriate as it can bias the interaction and may make the client feel judged or uncomfortable.
Correct Answer is C
Explanation
Choice A reason: Offering to contact the family's spiritual counselor can provide emotional and spiritual support, but it is not the immediate priority in a situation where the client has expressed a desire to have life support withdrawn.
Choice B reason: Discussing comfort measures is important for the client and family to understand what to expect during the withdrawal process. However, this step comes after the healthcare provider has been informed and a plan of care is being developed.
Choice C reason: Informing the healthcare provider is the priority nursing intervention. The nurse acts as an advocate for the client's wishes and ensures that the appropriate steps are taken to respect the client's autonomy and decisions regarding their care.
Choice D reason: Explaining the actions that the healthcare team will follow is an essential part of the process, but it is not the first step. The healthcare provider must first be informed so that the proper orders and arrangements can be made.
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