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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Isoniazid is an antitubercular drug that can cause urine to turn dark yellow or brown, not red-orange.

Choice B reason: Metoprolol is a beta-blocker that can cause urine to turn blue-green, not red-orange.

Choice C reason: Rifampin is an antitubercular drug that can cause urine to turn red-orange, as well as other body fluids such as saliva, sweat, and tears.

Choice D reason: Furosemide is a diuretic that can cause urine to become more concentrated and darker in color, but not red-orange.

A. Replace the unit when the drainage chamber is full. B. Pin the tubing to the client's bed sheets. C. Monitor for at least 150 mL of drainage every hour. D. Clamp the tube for 30 min every 8 hr.

Correct Answer is A

Explanation

The correct answer is A:

Choice A reason:

Replace the unit when the drainage chamber is full. This ensures continuous, effective drainage. A full chamber cannot collect more fluid, risking system compromise and patient safety.

Choice B reason:

Pinning the tubing to the bed sheets is incorrect because it can cause kinks in the tubing, leading to obstruction of drainage and potential complications.

Choice C reason:

Monitoring for at least 150 mL of drainage every hour is not a standard practice. Normal chest tube drainage is variable; excessive drainage, such as 150 mL/hour, could indicate a serious condition like hemorrhage.

Choice D reason:

Clamping the tube routinely for 30 minutes every 8 hours is not recommended. Clamping may be done during tube removal or to check for air leaks but doing so routinely can lead to tension pneumothorax.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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