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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Applying a lubricating lotion helps to combat dryness and maintain skin moisture, which is particularly beneficial as skin turgor decreases with age. This is a direct way to address common skin issues in older adults.
B. Padding bony prominences helps to prevent pressure ulcers but does not address the issue of decreased skin turgor directly.
C. Encouraging a high-protein diet is beneficial for overall skin health and repair but is not specifically aimed at addressing the immediate changes in skin turgor due to aging.
D. Bathing with mild soap is gentle on the skin but does not specifically address the loss of skin turgor. Using a lotion or moisturizer directly addresses the dryness and potential discomfort associated with aging skin.
Correct Answer is B
Explanation
A. White blood cell count is related to immune function and is not directly affected by water intoxication.
B. Serum sodium levels are the primary concern in cases of water intoxication. Excessive water intake can dilute the sodium in the blood, leading to hyponatremia, which can cause confusion, seizures, and other serious complications.
C. While serum potassium levels are important for overall electrolyte balance, they are not as immediately affected by water intoxication as sodium levels are.
D. Creatinine clearance is a measure of kidney function and does not directly relate to the immediate risks associated with water intoxication.
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