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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A child who has a forehead wound that is bleeding copiously: While bleeding wounds require attention, they are not immediately life-threatening compared to other injuries described.
B. A child who has a compound fracture of the femur and is crying in pain: While painful, a
femur fracture is not typically immediately life-threatening unless it is causing severe bleeding or compromising circulation.
C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake:
These symptoms suggest potential head trauma and require urgent evaluation to assess for intracranial injuries.
D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip: These injuries, while concerning, are not immediately life-threatening compared to the potential head injury described in option C.
Correct Answer is C
Explanation
A. Dependent edema is a sign of fluid overload or right-sided heart failure but is not immediately life-threatening.
B. A pericardial friction rub is a characteristic finding of pericarditis but does not indicate imminent compromise.
C. A paradoxical pulse (pulsus paradoxus) can indicate cardiac tamponade, a life-threatening complication of pericarditis. Prompt recognition and intervention are critical.
D. Substernal chest pain is a common symptom of pericarditis and should be addressed, but it is not as immediately dangerous as signs of cardiac tamponade.
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