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.

Answer and Explanation

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.

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Correct Answer is ["1.5"]

Explanation

Number of tablets = total dose/ tablet strength

= 30/20

= 1.5 tablets

A. percussion. B. deep palpation. C. auscultation. D. light palpation.

Correct Answer is C

Explanation

Choice A rationale: Percussion is typically performed after auscultation in the abdominal assessment sequence.
Choice B rationale: Deep palpation is usually performed after light palpation in the abdominal assessment sequence.
Choice C rationale: Auscultation is the next step in the abdominal assessment sequence after inspection. Assessing bowel sounds is crucial before moving on to other assessment techniques.
Choice D rationale: Light palpation is often the initial step in the abdominal assessment sequence, followed by auscultation.

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When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient is receiving 30 mg of citalopram daily for depression. Citalopram is available in 20 mg scored tablets. How many tablets should be administered? (Round to the nearest tenth.)

Correct Answer is ["1.5"]

Explanation

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:

Correct Answer is C

Explanation

A client comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. Which assessment techniques and diagnostic studies should the nurse use?

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

A wound care nurse has been consulted on a patient with multiple pressure wounds. The nurse comes across this heal wound. How should she document the following wound?

A nurse is providing education for an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?