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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This is a correct statement, because checking the heart rate each day can help monitor the function and effectiveness of the pacemaker, and detect any signs of malfunction, such as bradycardia, tachycardia, or irregular rhythm.

Choice B reason: This is an incorrect statement, because the client still needs to take the antihypertensive medications as prescribed, even with a pacemaker. The pacemaker regulates the heart rate, but does not control the blood pressure, which can be affected by other factors, such as stress, diet, or kidney function.

Choice C reason: This is an incorrect statement, because the client should avoid stretching the arms above the head for the first few weeks after the pacemaker insertion, as it can cause dislodgment or damage to the pacemaker leads. The client should limit the arm movements and activities until the incision site heals and the provider approves.

Choice D reason: This is an incorrect statement, because the client can stand in front of a microwave oven without any risk, as long as the oven is in good working condition and does not leak radiation. The modern microwave ovens and pacemakers are designed to prevent any interference or damage. However, the client should avoid close contact with other sources of electromagnetic fields, such as metal detectors, cell phones, or MRI machines.

A. Place the client in a private room B. Secure a dosimeter badge to the client's gown C. Don a cover gown before entering the client's room D. Dispose of dislodged implants in a biohazard sharps container

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Placing the client in a private room is a correct action, because it reduces the exposure of other clients and staff to the radiation source.

Choice B reason: Securing a dosimeter badge to the client's gown is an incorrect action, because the dosimeter badge is used to measure the radiation exposure of the staff, not the client. The client should wear an identification bracelet that indicates the type and location of the radiation source.

Choice C reason: Donning a cover gown before entering the client's room is a correct action, because it protects the nurse's clothing from contamination by the client's body fluids or secretions.

Choice D reason: Disposing of dislodged implants in a biohazard sharps container is a correct action, because it prevents the spread of radiation and infection. The nurse should also notify the radiation safety officer if an implant is dislodged.

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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?

Nursing Test Bank

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