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 d,b,e,a,c

Explanation

The sequence the nurse should use to administer the medication using the Z-track technique is:

- Step 1: Put on gloves and cleanse the site with an antiseptic swab.

- Step 2: Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally.

- Step 3: Insert the needle into the muscle.

- Step 4: Aspirate by pulling back on the plunger and inject the medication.

- Step 5: Remove the needle and release the tissue.

A. Apply restraints to the client. B. Administer an IV bolus of lorazepam. C. Place the client in the prone position. D. Insert a tongue blade into the client's mouth.

Correct Answer is B

Explanation

Choice A reason: Applying restraints to the client is not an appropriate action, as it can cause injury or suffocation to the client during a seizure. The nurse should protect the client from harm by removing any nearby objects and padding the side rails.

Choice B reason: Administering an IV bolus of lorazepam is an appropriate action, as lorazepam is an anticonvulsant drug that can stop or shorten the duration of a seizure by enhancing the inhibitory effects of gamma-aminobutyric acid (GABA) in the brain.

Choice C reason: Placing the client in the prone position is not an appropriate action, as it can obstruct the airway and cause respiratory distress or aspiration during a seizure. The nurse should place the client in the side-lying position to facilitate drainage of oral secretions and prevent tongue biting.

Choice D reason: Inserting a tongue blade into the client's mouth is not an appropriate action, as it can cause oral trauma or choking during a seizure. The nurse should never force anything into the client's mouth during a seizure and should allow them to breathe spontaneously.

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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

Correct Answer is d,b,e,a,c

Explanation

A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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