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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Calcium B. Vitamin B1 C. Protein D. Vitamin D

Correct Answer is C

Explanation

Choice A rationale: Calcium is essential for bone health but is not specifically emphasized in wound healing.
Choice B rationale: Vitamin B1 is important for energy metabolism but is not specifically emphasized in wound healing.
Choice C rationale: Protein is crucial for wound healing as it provides the building blocks for tissue repair and regeneration.
Choice D rationale: Vitamin D is important for bone health but is not specifically emphasized in wound healing.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is caring for a client who has a prescription for a stool test for occult. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

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 completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

5 fl oz = ____mL

A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

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?