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. Impaired bed mobility is a concern, especially for an immobile client, but addressing fluid volume deficit takes precedence due to its immediate impact on the client's health.
B. Fluid volume deficit is a critical issue, particularly with diarrhea, which can lead to dehydration and electrolyte imbalances. Ensuring adequate fluid intake and managing fluid balance is essential for preventing complications.
C. Bowel incontinence is a significant issue but managing fluid volume deficit is more urgent to prevent potential complications from dehydration.
D. Caregiver role strain is important, but the immediate priority should be addressing the client’s health needs, such as preventing and managing fluid volume deficit, which can impact overall well-being.

A. Place the client in a Trendelenburg position. B. Document the second reading in the client record. C. Securely place the prongs of the cannula in the nostrils. D. Place the pulse oximeter on the client's earlobe.

Correct Answer is C

Explanation

A. The Trendelenburg position is not appropriate for managing low oxygen saturation levels and may not address the underlying issue. This position is more commonly used for hypotension, not hypoxemia.
B. Documenting the reading is important for record-keeping but does not address the immediate concern of the client's low oxygen saturation levels.
C. Ensuring that the nasal cannula is securely placed in the nostrils is crucial for effective oxygen delivery. A loose or improperly positioned cannula can result in inadequate oxygenation, contributing to lower oxygen saturation readings.
D. While placing the pulse oximeter on the earlobe might provide a different reading, it is essential first to ensure that the current oxygen delivery system is functioning properly and the cannula is properly positioned.

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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

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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.

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

During the prodromal stage of an infection, which is the priority nursing intervention?

In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

The healthcare provider prescribes cefixime oral suspension 200 mg by mouth twice a day for an older adult who has difficulty swallowing pills. The bottle is labeled, "Cefixime for Oral Suspension, USP 100 mg per 5 mL." How many mL should the nurse administer daily? (Enter numerical value only.)

An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first?

A bedfast female client awakens during the night, reporting to the nurse that she is "uncomfortable." What action should the nurse implement first?

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.