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Exhibits

The practical nurse (PN) is preparing to change the turban dressing.

For each intervention, click to indicate whether it is indicated or not indicated for the dressing change. Each row must have one

A.

Clean the site using sterile gauze and sterile water.

B.

Place client in a private room.

C.

Avoid hand sanitizer after the procedure.

D.

Place the soiled dressing in a red biohazard bag.

E.

Use sterile gloves to remove

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

  1. Clean the site using sterile gauze and sterile water.
    • Indicated: The turban dressing should be changed using sterile techniques to prevent infection and ensure proper wound care.
  2. Place client in a private room.
    • Not Indicated: The client is already on contact precautions for MRSA, so the private room is a general requirement and not a specific intervention for the dressing change.
  3. Avoid hand sanitizer after the procedure.
    • Not Indicated: Hand sanitizer is typically used before and after procedures. For MRSA contact precautions, hand hygiene is critical, and proper hand washing or using hand sanitizer is recommended after the procedure.
  4. Place the soiled dressing in a red biohazard bag.
    • Indicated: The soiled dressing is considered contaminated and should be disposed of in a red biohazard bag to prevent the spread of infection.
  5. Use sterile gloves to remove the old dressing.
    • Indicated: Sterile gloves are required for removing and replacing the dressing to maintain a sterile field and prevent infection.


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Related Questions

Correct Answer is []

Explanation

The client’s symptoms—severe chest pain, nausea, dizziness, trembling, and diaphoresis—along with elevated troponin levels, are indicative of a myocardial infarction. Troponin is a cardiac biomarker used to diagnose myocardial infarction, and the client’s symptoms are consistent with this condition.

Actions to Take:

  1. Use Therapeutic Communication to Build Rapport
    Effective therapeutic communication helps the client feel supported and may reduce anxiety and fear related to their condition. This approach can provide a calm environment for the client, which is crucial when managing a myocardial infarction.
  2. Teach Coping Skills
    Teaching coping skills can help the client manage anxiety and stress, which are important for recovery from a myocardial infarction. Understanding how to cope with the emotional and psychological aspects of the condition supports overall care and management.

Parameters to Monitor:

  1. Heart Rhythm
    Monitoring heart rhythm is essential to detect any arrhythmias or complications related to myocardial infarction. Changes in heart rhythm can indicate worsening of the condition or response to treatment.
  2. Vital Signs
    Monitoring vital signs, including blood pressure and heart rate, is crucial for assessing the client’s hemodynamic status and the effectiveness of treatment. Abnormalities in vital signs can indicate worsening of the myocardial infarction or side effects of medications

Correct Answer is B

Explanation

A. Sliding hands under the lumbar area and knees can cause strain on the PN’s back and is not the safest method for turning a dependent client.
B. Using a turning sheet to turn the client away from the PN is the safest method for moving a dependent client, as it uses a proper technique that minimizes injury risk for both the client and the PN.
C. Raising bed rails on the opposite side may increase the risk of injury or falls, and is not directly related to the safe turning of the client.
D. Grasping the client's hand to pull them is unsafe and could cause injury or discomfort to both the client and the PN, especially when turning a dependent client.

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