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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Verifying the bilirubin level of the tube contents is incorrect. Measuring bilirubin levels in the tube contents is not a standard or reliable method for confirming tube placement. It's not an established or recommended technique for this purpose.
Choice B Reason:
Auscultating for air insufflation is incorrect. Auscultation for air insufflation involves injecting air into the tube and listening for bubbling sounds over the stomach area. While this method is commonly used, it can sometimes yield inconsistent or inconclusive results, especially in patients with certain conditions or situations where air movement might not be detectable.
Choice C Reason:
Request a chest x-ray is correct. Obtaining a chest x-ray is the most reliable method to confirm the placement of a feeding tube, especially when the tube is newly inserted or if there are any doubts about its location. A chest x-ray can accurately visualize the position of the tube within the gastrointestinal tract, ensuring it is in the intended location before any feedings or medications are administered.
Choice D Reason:
Checking the pH level of gastric contents is incorrect. Measuring the pH level of aspirated gastric contents can provide information about the acidity of the fluid, indicating gastric placement (pH below 5) in most cases. However, the pH can be influenced by various factors like medications, enteral feeding solutions, or certain medical conditions, making it less reliable than a chest x-ray for definitive confirmation of tube placement.
Correct Answer is A
Explanation
Choice A Reason:
Chlorine bleach is correct. Chlorine bleach is an effective disinfectant against bloodborne pathogens. It's recommended for cleaning surfaces contaminated with blood spills because it can destroy various microorganisms, including bacteria and viruses. However, it's essential to follow proper dilution guidelines and safety precautions when using bleach.
Choice B Reason:
Chlorhexidine gluconate is incorrect. While chlorhexidine gluconate is an antiseptic commonly used for skin disinfection before medical procedures or as a surgical scrub, it's not typically used for cleaning blood spills on surfaces. Its primary application is for skin disinfection, not environmental surface cleaning.
Choice C Reason:
Hydrogen peroxide is incorrect. Hydrogen peroxide is a mild antiseptic that can disinfect wounds or clean certain surfaces. However, it might not be as effective as chlorine bleach in dealing with blood spills. It's generally used more for superficial wound cleaning rather than for disinfecting large contaminated surfaces.
Choice D Reason:
Isopropyl alcohol is incorrect. Isopropyl alcohol is a commonly used disinfectant for surfaces, but when it comes to blood spills, it might not be as effective as chlorine bleach. While it can kill some pathogens, its efficacy against certain bloodborne pathogens may be limited compared to bleach.
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