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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Free Nursing Study Resources

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

Explanation

The correct answer is A, C, D

Choice A reason: Allopurinol is a medication that helps reduce the production of uric acid, which is beneficial for patients with gout and urolithiasis to prevent the formation of uric acid stones.

Choice B reason: While regular exercise is generally beneficial for overall health, it does not have a direct impact on the prevention of uric acid stone formation. Therefore, it is not a specific recommendation for preventing uric acid stone.

Choice C reason: Foods high in purines can increase uric acid levels in the body, leading to the formation of uric acid stones. Limiting the intake of such foods is a key step in preventing uric acid stones.

Choice D reason: Adequate fluid intake is crucial as it helps to dilute the urine, which can prevent the formation of uric acid stones by reducing the concentration of uric acid in the urine.

Choice E reason: Contrary to the statement, lemonade may actually be beneficial in preventing uric acid stones because it contains citrate, which can help prevent stone formation. Citrate can bind to calcium and prevent stone formation, and it also makes the urine less acidic, which can help prevent the formation of uric acid stones.

A. Reinforce teaching with the client about proper instillation of antibiotic eye drops. B. Apply warm compresses to the affected eye. C. Dim the lights in the client examination room. D. Inspect the eyes for drainage or redness.

Correct Answer is D

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:Option B (warm compresses)is a key intervention for blepharitis to improve meibomian gland function and reduce crusting. However, assessment (Option D) must precede treatment to ensure no contraindications (e.g., corneal abrasion) and tailor care appropriately.

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:Thefirst stepin the nursing process isassessment. Even with a diagnosis of blepharitis, the nurse mustinspect the eyesto evaluate the current severity, presence of drainage (e.g., purulent vs. serous), redness, or signs of secondary infection (e.g., bacterial involvement). This informs subsequent interventions.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse make? (Select all that apply)

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

Explanation

A nurse in a provider's office is caring for a client who has blepharitis. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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