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 B
Explanation
A. Place the client's valuables in the facility's safe - While securing the client's valuables is important, it is not the priority upon admission.
B. Observe the client's level of mobility - This is the priority as it allows the nurse to assess the client's immediate physical condition and risk of falls or other mobility-related issues.
C. Administer prescribed medications - Medication administration can wait until the client's initial assessment, including mobility, has been completed.
D. Electronically enter the prescriptions from the provider - Entering prescriptions can be done after the initial assessment and immediate needs of the client have been addressed.
Correct Answer is B
Explanation
- A: Diabetes mellitus is not listed as a contraindication for methylergonovine.
- B: Hypertension is a contraindication for methylergonovine because it can cause severe hypertension and other cardiovascular effects.
- C: Migraine headaches are not listed as a contraindication for methylergonovine.
- D: Hepatitis B is not listed as a contraindication for methylergonovine.
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