A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?

Adhesive tape

Tongue depressor

Syringe

Cotton-tipped applicator

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Adhesive tape is incorrect. Adhesive tape is commonly used for securing dressings or medical devices, but it may not be the primary supply needed for managing a stage 4 pressure injury. Wound care for a stage 4 pressure injury often involves specialized dressings, cleansing solutions, and applicators rather than adhesive tape alone.

Choice B Reason:

Tongue depressor is incorrect. A tongue depressor is typically used for oral examinations or to apply topical treatments to the mouth. It's not a standard supply for managing a stage 4 pressure injury, which requires specific wound care supplies designed for wound cleaning and dressing application.

Choice C Reason:

Syringe is incorrect. While syringes are versatile tools used in various medical procedures, in the context of managing a stage 4 pressure injury, their primary use might be for administering medications or irrigation solutions rather than being the essential supply for wound care in this specific instance.

For a client with a stage 4 pressure injury, the nurse should obtain supplies that are suitable for wound care. Among the options provided, the most appropriate supply is:

Choice D Reason:

Cotton-tipped applicator is correct. A cotton-tipped applicator can be used for wound cleaning and dressing application for a stage 4 pressure injury. It allows for gentle cleaning of the wound and application of topical treatments while minimizing trauma to the wound area.

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Correct Answer is A

Explanation

Choice A Reason:

This is the correct action. A filter needle should be used when drawing medication from an ampule to prevent glass particles from being aspirated into the syringe and subsequently administered to the patient.

Choice B Reason:

Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.

Choice C Reason:

This is not necessary. Once the ampule is opened, it should be handled with care to avoid contamination, but cleansing the tip with an alcohol swab is not a standard practice since it does not effectively remove glass particles.

Choice D Reason:

This is incorrect. Ampules are not pressurized containers, and injecting air into an ampule is unnecessary and could cause the medication to spill out or create bubbles that interfere with accurate dosing.

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A. Have the client sign an against medical advice form. B. Tell the client that the surgeon will prescribe restraints if they try to leave. C. Explain to the client that they cannot leave until the surgeon discharges them. D. Administer a sedative medication to the client.

Correct Answer is C

Explanation

Choice A Reason:

Have the client sign an against medical advice (AMA) form is incorrect. While this form allows patients to leave against medical advice after acknowledging the risks, it should be used after thorough discussion, ensuring the patient understands the consequences. In this case, the client is postoperative and might not have received clearance from the surgeon, so this option may not be appropriate without further assessment.

Choice B Reason:

Tell the client that the surgeon will prescribe restraints if they try to leave is incorrect. Threatening restraints is not a suitable or ethical approach. Using restraints should be a last resort for ensuring safety, especially if a patient is attempting to leave. It's crucial to communicate and engage in dialogue rather than resorting to threats or coercion.

Choice C Reason:

Explain to the client that they cannot leave until the surgeon discharges them is correct. This action prioritizes the safety and well-being of the client while also informing them of the necessary procedure before leaving the hospital. It's essential to communicate the discharge process and ensure that the client understands the potential risks of leaving without proper medical approval. This approach maintains respect for the client's autonomy while emphasizing the importance of following the medical protocol for a safe recovery.

Choice D Reason:

Administer a sedative medication to the client is incorrect. Using sedatives to prevent a patient from leaving is not ethically or medically appropriate unless there's a critical situation where the patient is a danger to themselves or others. Administering sedatives without proper justification or consent violates ethical principles and could potentially harm the patient.

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A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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