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
Clean the site using sterile gauze and sterile water.
Place client in a private room.
Avoid hand sanitizer after the procedure.
Place the soiled dressing in a red biohazard bag.
Use sterile gloves to remove
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
- 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.
- 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.
- 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.
- 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.
- 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Monitoring daily sodium intake is important for managing AKI, but it is not the immediate priority when addressing acute changes in heart rate and blood pressure.
B. Recording usual eating patterns is not relevant to the immediate concern of elevated heart rate and blood pressure in the context of AKI.
C. Documenting abdominal girth is relevant for assessing fluid status and potential complications like ascites, but it is not the first priority for addressing the acute symptoms of elevated heart rate and blood pressure.
D. Measuring and documenting urinary output is the most critical intervention because it provides essential information on kidney function and fluid balance, which directly impacts heart rate and blood pressure management in AKI.
Correct Answer is D
Explanation
A. Administering half of the missed dose is not generally recommended because it could lead to inconsistent drug levels and potential for breakthrough seizures. The standard practice is to follow the dosing schedule unless otherwise instructed by the healthcare provider.
B. Giving the missed dose with the next scheduled dose may lead to double dosing and could increase the risk of side effects or toxicity. The missed dose should be addressed as soon as possible but not in combination with the next dose.
C. Withholding the missed dose unless seizure activity occurs could put the client at risk for seizures. Anticonvulsants should be administered as per the prescribed schedule to maintain therapeutic drug levels and prevent seizures.
D. Administering the missed dose as soon as possible is the correct approach, following standard guidelines for missed medications. The missed dose should be given promptly unless it is close to the time of the next dose, in which case the next dose should be given as scheduled.
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