When preparing to change a sterile dressing over an incision, it is most important to remember to:

Remind him to remain very still during the procedure.

Place a discard bag close to the wound.

Change gloves after removing the old dressing.

Refrain from talking while the wound is uncovered.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While it’s important for the patient to remain still during the procedure, this is not the most important aspect of changing a sterile dressing.

Choice B rationale:

Placing a discard bag close to the wound can increase the risk of infection.

Choice C rationale:

Changing gloves after removing the old dressing is crucial to maintain sterility and prevent infection.

Choice D rationale:

Refraining from talking while the wound is uncovered can help prevent infection, but it’s not as important as changing gloves after removing the old dressing.

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Correct Answer is C

Explanation

Choice A rationale:

Full thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not stage 1.

Choice B rationale:

Full thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not stage 1.

Choice C rationale:

Stage 1 pressure injuries are characterized by intact skin with localized erythema.

Choice D rationale:

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not stage 1.

A. BMI of 20. B. Peripheral neuropathy. C. Immobility. D. Hypoperfusion. E. Prealbumin level of 16 mg/dL. .

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of pressure injuries.

Choice B rationale:

Peripheral neuropathy can lead to decreased sensation, increasing the risk of pressure injuries as the person may not feel discomfort from prolonged pressure.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases the duration of pressure on certain areas of the body.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue damage and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is within the normal range (15-36 mg/dL), so it does not increase the risk of pressure injuries.

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When preparing to change a sterile dressing over an incision, it is most important to remember to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

Correct Answer is ["B","C","D"]

Explanation

The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.You would document this wound as:

A nurse is assisting with the care of a client who has an infected wound with significant exudate.Which of the following dressings should the nurse plan to cover the client's wound?

The nurse reminds the 85-year-old patient that his healing will be slower because of age-related changes such as: (Select all that apply.)

The nurse assesses the large raised scar on the African American patient.The nurse documents the lesion as a:

While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood.Which is the appropriate action for you to take at this time?

A nurse is caring for a client who has heavy drainage from a moist red wound that is bleeding.Which of the following types of dressings should the nurse select to help promote hemostasis?

Chronic wounds that are not healing well may benefit from (Select all that apply.)

The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed.The nurse's most beneficial intervention would be to: