Exhibits

The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.

Gather materials to change soiled items only

Thoroughly clean wound using normal saline prior to redressing

Place sterile gauze directly on wound bed

Apply sterile gloves prior to changing

Apply sterile foam dressing over wound bed

Maintain clean medical asepsis

Answer and Explanation

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

Gather materials to change soiled items only: Not indicated. The nurse should gather all necessary materials for the entire wound care procedure, not just for changing soiled items, to ensure the dressing change is performed efficiently and effectively.
Thoroughly clean wound using normal saline prior to redressing: Indicated. Proper wound cleaning with normal saline helps remove debris and reduce bacterial load, preparing the wound for the application of new dressings.
Place sterile gauze directly on wound bed: Not indicated. The wound care order specifies the use of anasept gel covered with foam dressing. Sterile gauze is not the appropriate dressing in this scenario.
Apply sterile gloves prior to changing: Indicated. Sterile gloves are necessary to maintain sterility and prevent infection during the dressing change procedure.
Apply sterile foam dressing over wound bed: Indicated. The orders specify the use of a foam dressing after applying anasept gel, which provides the necessary coverage and protection for the wound.
Maintain clean medical asepsis: Not indicated. While maintaining a clean environment is important, sterile technique (rather than clean medical asepsis) is required for this dressing change to prevent infection and promote healing in the wound bed.

Nursing Test Bank

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Correct Answer is B

Explanation

A. The hospital pharmacist can provide valuable information about medication dosages and potential discrepancies, but the primary source for clarification about the prescribed treatment plan is the healthcare provider who issued the prescription.
B. The healthcare provider should be contacted first to clarify the dosage discrepancy. The provider can confirm whether the dosage is correct or if there was an error in the prescription. This ensures that any potential issues are addressed by the person responsible for the treatment plan.
C. A medication reference guide is useful for checking normal dosages, but it does not clarify if a specific prescription is appropriate for the client’s condition. The provider’s confirmation is necessary for resolving discrepancies.
D. The nursing unit charge nurse may be consulted for additional guidance but is not the primary resource for verifying or resolving prescription dosages.

A. Muscle strength and tone. B. Presence of rebound phenomenon. C. Limitations to range of motion. D. Degree of neurosensory impairment.

Correct Answer is D

Explanation

A. Muscle strength and tone are important assessments but are not directly related to the safe use of a heating pad.
B. The rebound phenomenon, where the effects of heat application reverse after prolonged exposure, is a consideration, but not as crucial as assessing for neurosensory impairment.
C. Limitations to range of motion may be important for mobility assessments but are less relevant to the safe application of heat therapy.
D. Assessing the degree of neurosensory impairment is most important before applying a heating pad. If the client has impaired sensation, they may not be able to detect if the heating pad is too hot, which could lead to burns or other injuries.

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Exhibits The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is D

Explanation

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Exhibits

The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.