A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?

Volunteer to provide an inservice about infection control.

Speak with the AP when he exits the room about the appropriate protocol.

Provide the appropriate PPE to the AP.

Notify the charge nurse about the AP's need for training.

Answer and Explanation

The Correct Answer is C

A. Volunteer to provide an inservice about infection control. While providing an inservice about infection control is important, it is not the immediate priority. The nurse needs to address the current situation to prevent potential contamination and infection spread.

B. Speak with the AP when he exits the room about the appropriate protocol. Speaking with the AP about the appropriate protocol is necessary, but it should be done after ensuring the immediate safety of the client and others. Delaying action could result in exposure to infectious agents.

C. Provide the appropriate PPE to the AP. This action addresses the immediate risk of infection transmission. By providing the appropriate PPE, the nurse ensures that the AP can safely continue their duties without putting themselves or the client at risk.

D. Notify the charge nurse about the AP's need for training. Notifying the charge nurse is important for long-term improvement, but it does not address the immediate risk. The nurse must first ensure that the AP is properly equipped to handle the current situation safely.

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Correct Answer is A

Explanation

The correct answer is choice A. Transparent dressing.

Choice A rationale:

Transparent dressings are appropriate for stage I pressure ulcers. These dressings provide a moist environment that promotes healing and protects the wound from external contaminants. They are also transparent, allowing the nurse to monitor the wound without removing the dressing. As stage I pressure ulcers involve intact skin with non-blanchable redness, these dressings aid in preventing friction and shear forces that could exacerbate the injury.

Choice B rationale:

Alginate dressings (Choice B) are not suitable for stage I pressure ulcers. Alginate dressings are highly absorbent and are generally used for wounds with moderate to heavy exudate, such as infected wounds or those with necrotic tissue. They may not be the best choice for a stage I pressure ulcer, which is characterized by superficial skin involvement without exudate or necrosis.

Choice C rationale:

Hydrogel dressings (Choice C) are beneficial for wounds with minimal to no exudate, but they are more appropriate for partial-thickness wounds, burns, or dry wounds. They provide a moist environment and promote autolytic debridement. However, in the case of a stage I pressure ulcer, where the skin is intact and there is no exudate, hydrogel dressings may not be the ideal choice.

Choice D rationale:

Wet-to-dry gauze dressings (Choice D) involve placing moist saline gauze onto a wound bed and allowing it to dry before removal. This method is used for mechanical debridement of wounds with necrotic tissue, and it's not suitable for a stage I pressure ulcer. In fact, using wet-to-dry dressings on a superficial wound could cause trauma and hinder healing.

A. Apply a moisture barrier ointment to the client's skin. B. Request a prescription for the insertion of an indwelling urinary catheter. C. Reposition the client every 8 hours to prevent skin breakdown. D. Check the client's skin every 8 hours for signs of breakdown.

Correct Answer is A

Explanation

Choice A rationale:

Applying a moisture barrier ointment helps protect the skin from the effects of moisture exposure due to urinary incontinence. Prolonged exposure to urine can lead to skin breakdown, irritation, and infection. A moisture barrier ointment creates a protective barrier, reducing the risk of skin damage.

Choice B rationale:

Requesting a prescription for an indwelling urinary catheter is not typically the first intervention to prevent skin breakdown in clients with urinary incontinence. Catheters carry their own set of risks, including infection, and should be considered after other interventions have been explored.

Choice C rationale:

Repositioning the client every 8 hours is important for preventing pressure ulcers but may not be sufficient to prevent skin breakdown due to urinary incontinence. Clients with urinary incontinence should be repositioned more frequently to address the effects of moisture.

Choice D rationale:

Checking the client's skin every 8 hours is an important step, but it alone may not effectively prevent skin breakdown. Incontinence-associated dermatitis can develop quickly, so it's essential to implement protective measures like using a moisture barrier ointment.

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A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Correct Answer is A

Explanation

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Correct Answer is A

Explanation

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