A nurse is caring for a client who has a stage III pressure ulcer on his heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?
Obtain the prescribed irrigation solution.
Don personal protective equipment.
Check the client's pain level.
Place a waterproof pad under the client's extremity.
The Correct Answer is C
Choice A reason: This is an important action, but not the first one. The nurse should obtain the prescribed irrigation solution after assessing the client's pain level and providing analgesia if needed.
Choice B reason: This is an important action, but not the first one. The nurse should don personal protective equipment after assessing the client's pain level and providing analgesia if needed.
Choice C reason: This is the correct action, because checking the client's pain level is the first step in the wound care process. The nurse should assess the client's pain level using a valid and reliable pain scale, and administer analgesia as prescribed before irrigating the wound.
Choice D reason: This is an important action, but not the first one. The nurse should place a waterproof pad under the client's extremity after assessing the client's pain level and providing analgesia if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the best intervention, because offering the client a bedpan every 2 hr can help prevent urinary retention, bladder distension, and infection, which can worsen the incontinence. It can also help maintain the client's dignity and comfort, and promote bladder retraining.
Choice B reason: This is an incorrect intervention, because limiting the client's daily fluid intake can cause dehydration, constipation, and urinary tract infection, which can aggravate the incontinence. The client should drink adequate fluids, unless the provider instructs otherwise.
Choice C reason: This is an incorrect intervention, because requesting a prescription for an indwelling urinary catheter is not recommended for a client who has occasional urinary incontinence. An indwelling urinary catheter can increase the risk of infection, trauma, and obstruction, and interfere with the bladder function. The nurse should use other methods of bladder management, such as intermittent catheterization, external catheter, or incontinence pads.
Choice D reason: This is an incorrect intervention, because ambulating the client to the bathroom every 30 min can be unrealistic, exhausting, and unsafe for a client who has hemiplegia, or paralysis of one side of the body, due to a stroke. The client may not be able to walk or transfer without assistance, and may fall or injure themselves. The nurse should assess the client's mobility and ability to use the bathroom, and provide appropriate aids and support.
Correct Answer is B
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should first address the client's comfort and inflammation before teaching them how to use the eye drops.
Choice B reason: This is the correct action, because warm compresses can help loosen the crusts and scales on the eyelids, reduce the swelling and irritation, and promote healing.
Choice C reason: This is a helpful action, but not the first one. The nurse should first apply warm compresses to the affected eye, and then dim the lights to reduce the sensitivity and pain.
Choice D reason: This is a necessary action, but not the first one. The nurse should first apply warm compresses to the affected eye, and then inspect the eyes for signs of infection or complications.
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