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 pallor is not a sign of anaphylaxis. Pallor can indicate shock, anemia, or hypoxia.
Choice B: This is incorrect because peripheral edema is not a sign of anaphylaxis. Peripheral edema can indicate heart failure, kidney disease, or venous insufficiency.
Choice C: This is incorrect because hypertension is not a sign of anaphylaxis. Hypertension can indicate stress, pain, or renal disease.
Choice D: This is correct because pruritus is a sign of anaphylaxis. Pruritus is a severe itching sensation that can accompany hives, rash, or angioedema.
Correct Answer is C
Explanation
Choice A: This is incorrect because taking iron supplement with an antacid can reduce its absorption and effectiveness. The client should take iron supplement on an empty stomach or with a source of vitamin C to enhance its absorption.
Choice B: This is incorrect because drinking liquid iron supplement undiluted can stain the teeth and cause irritation to the mouth and throat. The client should dilute liquid iron supplement with water or juice and drink it through a straw.
Choice C: This is correct because increasing fiber intake while taking iron supplement can help prevent constipation, which is a common side effect of iron supplementation. The client should also drink plenty of fluids and exercise regularly to promote bowel movements.
Choice D: This is incorrect because notifying the doctor if stools turn black is not necessary as it is a normal and harmless effect of iron supplementation. The client should only notify the doctor if stools are tarry, bloody, or have a foul odor, which can indicate gastrointestinal bleeding.
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