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 A
Explanation
Choice A reason: HbA1c or glycated hemoglobin is a measure of average blood glucose levels over the past 2 to 3 months. A lower HbA1c indicates better glycemic control and a lower risk of diabetes complications. The target HbA1c for most people with diabetes mellitus is less than 7%.
Choice B reason: HbA1c 12.5% is very high and indicates poor glycemic control and a high risk of diabetes complications, such as retinopathy, nephropathy, or neuropathy.
Choice C reason: Fasting blood glucose 100 mg/dL is within the normal range of 70 to 99 mg/dL and indicates normal glucose metabolism, but it does not reflect the long-term control of blood glucose levels over the past 3 months.
Choice D reason: Fasting blood glucose 70 mg/dL is at the lower end of the normal range and may indicate hypoglycemia or low blood glucose levels, which can cause symptoms such as sweating, trembling, hunger, or confusion.
Correct Answer is C
Explanation
Choice A reason: WBC count 10,000/mm³ is within the normal range of 4,500 to 11,000/mm³ and does not indicate any infection or inflammation.
Choice B reason: BUN 20 mg/dL is within the normal range of 10 to 20 mg/dL and does not indicate any renal impairment or dehydration.
Choice C reason: Creatinine 2.3 mg/dL is above the normal range of 0.6 to 1.2 mg/dL and indicates renal dysfunction or damage, which can be caused by blood loss, hypotension, or nephrotoxic drugs during surgery. The nurse should report this value to the provider and monitor the client for signs of acute kidney injury, such as oliguria, edema, or electrolyte imbalances.
Choice D reason: Hematocrit 41% is within the normal range of 37% to 47% for females and does not indicate any anemia or polycythemia.
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