A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?
Determine the client's pain level.
Irrigate the wound with 0.9% sodium chloride irrigation.
Apply skin preparation to wound edges.
Don sterile gloves.
The Correct Answer is A
A.
A. Assessing the client's pain level is the first step to ensure appropriate pain management during the procedure.
B. Irrigating the wound comes after assessing the client's pain level and preparing the wound for the dressing change.
C. Applying skin preparation to wound edges is part of the preparation process but should come after assessing the client's pain level.
D. Donning sterile gloves is necessary for the procedure but should come after assessing the client's pain level.
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Related Questions
Correct Answer is A
Explanation
A.
A. The priority action is to remove the client from the source of carbon monoxide poisoning, which in this case is the kerosene space heater. Taking the client outdoors will provide fresh air and reduce exposure to carbon monoxide.
B. Wrapping blankets around the client may further exacerbate the symptoms by trapping the carbon monoxide, worsening the client's condition.
C. While loosening the client's clothing may improve ventilation, it is not as effective as removing the client from the source of exposure.
D. Opening the client's windows may help improve ventilation, but it is not as effective as taking the client outdoors to reduce exposure to carbon monoxide.
Correct Answer is C
Explanation
A. Encouraging the parents to suppress their grief can be detrimental to their emotional well- being and may inhibit healthy grieving processes.
B. Avoiding discussing the funeral when the child is around may create confusion and anxiety for the child, who may sense that something significant is happening but is excluded from the discussion.
C. Including the child in the funeral service before visitors arrive allows the child to be part of the grieving process and provides an opportunity for closure and understanding of the sibling's death in a supportive environment.
D. While it is important for parents to understand how school-age children perceive death, this statement does not offer guidance on how to support the child during the grieving process.
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