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 B
Explanation
Choice A reason: Maintaining the client's head of the bed at 20% is an incorrect action, because the head of the bed should be elevated at least 30% to prevent aspiration of the feeding.
Choice B reason: Monitoring the client’s blood glucose level is a correct action, because enteral feedings can affect the blood glucose level and the client may need insulin adjustments.
Choice C reason: Flushing the enteral feeding tube with 10 mL of cool water after each medication is an incorrect action, because cool water can cause cramping and nausea. The nurse should use warm water to flush the tube and use at least 30 mL of water to prevent clogging.
Choice D reason: Obtaining an x-ray after beginning the feeding is an incorrect action, because an x-ray should be obtained before starting the feeding to confirm the placement of the tube.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect statement, because the client should not share razors with anyone, even if they are disposable. Razors can cause cuts and bleeding, which can transmit the HIV virus and other infections. The client should use their own personal hygiene items and dispose of them safely.
Choice B reason: This is the correct statement, because the client should clean bathroom surfaces with a bleach and water solution. Bleach is a disinfectant that can kill germs and prevent the spread of infections. The client should also wash their hands frequently and avoid contact with bodily fluids.
Choice C reason: This is an incorrect statement, because the client should not increase their intake of raw fruits and vegetables. Raw fruits and vegetables can contain bacteria, parasites, or pesticides, which can cause infections and complications in the client who has a weakened immune system. The client should wash and cook their fruits and vegetables thoroughly before eating them.
Choice D reason: This is an incorrect statement, because the client should not continue their hobby of gardening, even if they wear a mask. Gardening can expose the client to soil, dust, fungi, or insects, which can cause infections and allergies in the client who has a compromised immune system. The client should avoid activities that can increase their risk of infection.
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