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 B

Explanation

A. Asking the assist personnel to document the client's time of death is not correct. While accurate documentation of the time of death is important, the responsibility typically falls on the healthcare provider or physician who confirms the death, not necessarily the assist personnel involved in postmortem care. B. Place an identification tag on the outside of the client's shroud is correct. This action ensures proper identification throughout the postmortem process and aligns with standard procedures for maintaining identification integrity during autopsy procedures. Identifying the client accurately is crucial to prevent any errors or mix-ups. C. Wearing sterile gloves when cleaning the client's body is incorrect. Sterile gloves are not typically required for postmortem care. While gloves are important for infection control, they don't necessarily need to be sterile for handling deceased patients unless there are specific infectious concerns. D. Removing the client's dentures and give them to the client's family is incorrect. In most cases, the client's personal belongings, including dentures, are typically handled according to specific protocols or the family's wishes. However, removing the dentures and giving them to the family isn't typically part of postmortem care. The family might be informed about the presence of dentures and their disposition, but the decision to give them to the family should follow established procedures or the family's preferences.

A. Turn on loud music in client care areas. B. Assign different nurses to provide care for clients each day. C. Offer the clients many choices regarding care. D. Restrict the number of visitors for clients.

Correct Answer is D

Explanation

Choice A Reason:

Turn on loud music in client care areas is incorrect. This action might increase stress rather than reduce it. Loud noises or music can be distressing for clients, especially in a healthcare setting where rest and recovery are crucial. It's generally better to maintain a calm and quiet environment.

Choice B Reason:

Assign different nurses to provide care for clients each day is incorrect. Continuity of care is often beneficial for clients, as it fosters trust and familiarity. Having different nurses daily might disrupt this continuity and potentially increase stress for clients who prefer consistent caregivers.

Choice C Reason:

While offering some choices can empower clients and reduce stress, too many choices might overwhelm them, particularly in an acute care setting. The key is to provide a balance of autonomy while not overwhelming the client.

Choice D Reason:

Limiting the number of visitors can help create a quieter, more controlled environment, reducing overstimulation and stress for clients. This can be particularly important in an acute care setting where rest and a calm environment are crucial for recovery.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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