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 C
Explanation
Choice A: This is incorrect. The Sims' position is not used for a colposcopy, which is a procedure that examines the cervix with a magnifying device. The client should be placed in the lithotomy position, which involves lying on the back with the legs spread and supported by stirrups.
Choice B: This is incorrect. The nurse should not insert a tampon following the procedure, as this can introduce bacteria and cause infection. The nurse should advise the client to use sanitary pads instead.
Choice C: This is correct. The nurse should instruct the client to avoid sexual intercourse until the cervix is healed, which can take up to a week. Sexual intercourse can cause bleeding, pain, and infection.
Choice D: This is incorrect. The nurse should not reinforce teaching that the procedure involves dilation of the cervix, as this is not true. A colposcopy does not require dilation of the cervix, unlike some other procedures such as endometrial biopsy or hysteroscopy.
Correct Answer is C
Explanation
Choice A: This is incorrect because blood glucose 98 mg/dL is within the normal range of 70 to 110 mg/dL. The nurse does not need to notify the provider for this value.
Choice B: This is incorrect because BUN 18 mg/dL is within the normal range of 10 to 20 mg/dL. The nurse does not need to notify the provider for this value.
Choice C: This is correct because hemoglobin 8.6 g/dL is below the normal range of 12 to 18 g/dL. The nurse should notify the provider for this value as it indicates anemia, which can be caused by blood loss during surgery or impaired bone marrow function.
Choice D: This is incorrect because potassium 3.5 mEq/L is within the normal range of 3.5 to 5.0 mEq/L. The nurse does not need to notify the provider for this value.
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