A nurse is preparing to perform a sterile dressing change for a client who has a stage III pressure ulcer. Which of the following actions should the nurse plan to take?
Don sterile gloves before removing the dressing.
Offer the client pain medication before the procedure.
Prepare the sterile dressing supplies 30 min before the dressing change.
Disinfect the wound bed with alcohol before applying tape.
The Correct Answer is B
Choice A: This is incorrect. The nurse should don clean gloves before removing the dressing, and then change to sterile gloves before applying the new dressing.
Choice B: This is correct. The nurse should offer the client pain medication before the procedure, as changing a dressing for a stage III pressure ulcer can be very painful.
Choice C: This is incorrect. The nurse should prepare the sterile dressing supplies just before the dressing change, not 30 min before, to prevent contamination.
Choice D: This is incorrect. The nurse should not disinfect the wound bed with alcohol, as this can damage the healthy tissue and delay healing. The nurse should use a saline solution or an antiseptic solution as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: This is incorrect. The client having difficulty reading large print indicates a need for an ophthalmology referral, not an occupational therapy referral. An ophthalmologist can assess and treat vision problems caused by stroke.
Choice B: This is incorrect. The client coughing while drinking from a straw indicates a need for a speech therapy referral, not an occupational therapy referral. A speech therapist can assess and treat swallowing problems caused by stroke.
Choice C: This is incorrect. The client being unable to bear her full weight while walking indicates a need for a physical therapy referral, not an occupational therapy referral. A physical therapist can assess and treat mobility problems caused by stroke.
Choice D: This is correct. The client becoming exhausted after performing activities of daily living indicates a need for an occupational therapy referral. An occupational therapist can assess and treat functional problems caused by stroke, such as fatigue, self-care, cognition, and leisure activities.
Correct Answer is C
Explanation
Choice A: This is incorrect because taking iron supplement with an antacid can reduce its absorption and effectiveness. The client should take iron supplement on an empty stomach or with a source of vitamin C to enhance its absorption.
Choice B: This is incorrect because drinking liquid iron supplement undiluted can stain the teeth and cause irritation to the mouth and throat. The client should dilute liquid iron supplement with water or juice and drink it through a straw.
Choice C: This is correct because increasing fiber intake while taking iron supplement can help prevent constipation, which is a common side effect of iron supplementation. The client should also drink plenty of fluids and exercise regularly to promote bowel movements.
Choice D: This is incorrect because notifying the doctor if stools turn black is not necessary as it is a normal and harmless effect of iron supplementation. The client should only notify the doctor if stools are tarry, bloody, or have a foul odor, which can indicate gastrointestinal bleeding.
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