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 because weight loss is not the highest priority finding for the nurse to report to the provider. Weight loss can be a common symptom of leukemia due to decreased appetite, increased metabolism, or malabsorption.
Choice B: This is incorrect because fatigue is not the highest priority finding for the nurse to report to the provider. Fatigue can be a common symptom of leukemia due to anemia, infection, or poor nutrition.
Choice C: This is incorrect because dysuria is not the highest priority finding for the nurse to report to the provider. Dysuria can indicate a urinary tract infection, which can be treated with antibiotics and fluids.
Choice D: This is correct because elevated temperature is the highest priority finding for the nurse to report to the provider. Elevated temperature can indicate a serious infection, which can be life-threatening for a client who has leukemia and a compromised immune system.
Correct Answer is B
Explanation
Choice A: This is incorrect because maintaining the client on bed rest can increase the risk of complications such as pneumonia, thromboembolism, or pressure ulcers. The nurse should encourage early ambulation and frequent position changes to promote healing and prevent complications.
Choice B: This is correct because repositioning the client can help relieve pressure and discomfort from the incision site. The nurse should assist the client to change positions every 2 hours and use pillows or splints to support the incision.
Choice C: This is incorrect because applying a warm, moist compress to the incision area can interfere with wound healing and increase the risk of infection. The nurse should keep the incision site clean and dry and follow the provider's orders for dressing changes.
Choice D: This is incorrect because administering an additional dose of pain medication is not necessary when the client reports a pain level of 2 on a scale of 0 to 10. The nurse should monitor the client's pain level and administer pain medication as prescribed and as needed.
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