When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?
Perform hand hygiene.
Assess the condition of the visible wound bed.
Measure the width of the wound with a disposable ruler.
Insert a swab into the wound at 90 degrees.
The Correct Answer is A
Choice A rationale: Performing hand hygiene before any wound care procedure is essential to prevent infection and maintain aseptic technique.
Choice B rationale: Assessing the condition of the visible wound bed is an important step but not the first action. Hand hygiene should precede any assessment or intervention.
Choice C rationale: Measuring the width of the wound with a disposable ruler is part of the wound measurement process but should follow hand hygiene.
Choice D rationale: Inserting a swab into the wound at 90 degrees is not the first step. Hand hygiene and assessment should precede any invasive procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Performing hand hygiene before any wound care procedure is essential to prevent infection and maintain aseptic technique.
Choice B rationale: Assessing the condition of the visible wound bed is an important step but not the first action. Hand hygiene should precede any assessment or intervention.
Choice C rationale: Measuring the width of the wound with a disposable ruler is part of the wound measurement process but should follow hand hygiene.
Choice D rationale: Inserting a swab into the wound at 90 degrees is not the first step. Hand hygiene and assessment should precede any invasive procedures.
Correct Answer is A
Explanation
Choice A rationale: Dark amber, cloudy, and unpleasant-smelling urine may indicate a urinary tract infection.
Choice B rationale: Urinary retention is not typically associated with dark amber, cloudy urine.
Choice C rationale: Cloudy urine may be associated with urinary incontinence but is not typically dark amber with an unpleasant odor.
Choice D rationale: Urinary frequency does not typically cause dark amber, cloudy urine.
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