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 AReason:
Encouraging the client to abstain from distracting activities is incorrect. Engaging in distracting activities can actually be beneficial in pain management. It can redirect the client's focus away from the pain, potentially reducing its intensity.
Choice BReason:
Ensuring that the client's room is kept at a cool temperature is incorrect.
While temperature can influence comfort, maintaining a cool room might not directly address or alleviate the client's pain.
Choice C Reason:
Playing music in the client's room is correct. Music therapy is a nonpharmacological intervention that can effectively help in managing pain. Calming or soothing music can distract the client from pain, reduce anxiety, and promote relaxation, potentially reducing the perception of pain.
Choice D Reason:
Keep the client's room well-lit is incorrect. The lighting in the room might not significantly impact pain levels. Some individuals might prefer dim lighting for relaxation, but it might not directly influence pain perception.
Correct Answer is D
Explanation
Choice A Reason:
Checking the medical record for the client's signature on a previous consent form is incorrect. While a previous consent form might exist in the medical records, for certain procedures or situations, specific, current consent for each instance is often necessary. Verifying a previous consent form may not ensure the client's informed consent for the current procedure.
Choice B Reason:
Having another nurse co-sign the client's consent is incorrect. Co-signing a client's consent by another nurse doesn't substitute for the client's own signature and may not adequately verify the client's informed decision and understanding of the procedure.
Choice C Reason:
Obtaining verbal consent from the client is incorrect. While obtaining verbal consent is important, for invasive procedures like catheter insertion, it's essential to have written, witnessed consent to ensure proper documentation and confirmation that the client is fully informed and agrees to the procedure.
Choice D Reason:
Witnessing the client's signature on a consent form is correct. Express consent for medical procedures typically involves the client signing a consent form after being adequately informed about the procedure, its potential risks, benefits, and alternatives. Witnessing the client's signature on a consent form ensures that the client has provided informed consent for the specific procedure.
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