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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Profuse milky white discharge: Bacterial vaginosis is characterized by a fishy odor and a thin, homogeneous, grayish-white discharge, not milky white. However, this option is the most closely associated with bacterial vaginosis among the choices provided.
B. Frequency and dysuria: These symptoms are more indicative of urinary tract infection rather than bacterial vaginosis.
C. Low-grade fever: Fever is not typically associated with bacterial vaginosis unless there is a secondary infection present.
D. Hematuria: Hematuria, or blood in the urine, is not a typical symptom of bacterial vaginosis.
Correct Answer is C
Explanation
A. Rupturing the amniotic sac in the case of complete placenta previa can lead to significant bleeding and is contraindicated.
B. Pain medication may be administered if needed, but the priority is to address the placenta previa and potential complications.
C. Complete placenta previa at 36 weeks gestation with contractions and bleeding is a clear
indication for an emergency cesarean section to prevent maternal hemorrhage and fetal distress.
D. Performing a vaginal exam can increase the risk of bleeding and should be avoided in cases of placenta previa.
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