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: Taking the client to the toilet when they have the urge to defecate promotes a natural bowel pattern and is an essential aspect of bowel training.
Choice B rationale: Timing toilet visits based on a regular schedule may be part of a bowel training program, but waiting for the client to have the urge is more effective.
Choice C rationale: Timing toilet visits with meals may be part of a bowel training program, but taking the client when they have the urge is more effective.
Choice D rationale: Waiting for the client to experience abdominal cramping may lead to delayed toileting and is not recommended in a bowel training program.
Correct Answer is D
Explanation
Choice A rationale: The stool test for occult blood is not primarily designed to detect bacteria.
Choice B rationale: Parasites are not typically detected through a stool test for occult blood.
Choice C rationale: Steatorrhea refers to the presence of excess fat in the stool and is not the primary focus of a stool test for occult blood.
Choice D rationale: The purpose of the stool test for occult blood is to check for the presence of blood in the stool, which may not be visible to the naked eye. This can be an indicator of gastrointestinal bleeding.
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