Wound Care
A nurse is assisting with preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements indicates that the client understands medical asepsis?
"I'll wash my hands before I remove the old dressing and again before putting on the new one."
A nurse is reinforcing teaching with a newly hired nurse about violations of client rights. Which of the following should the nurse include as an example of a violation of client rights?
A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at nurses of the opposite sex.
A nurse is prioritizing care for a group of clients. The nurse should plan to attend to which of the following clients first?
A client who requires endotracheal suctioning
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement?
Apply a gown when in the client's room
A nurse is caring for a client who has a stage Ill pressure ulcer on his heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?
Check the client's pain level
A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when explaining the procedure to the client?
Ensure the interpreter and the client speak the same dialect
A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique?
Keeping microorganisms from entering the wound
A nurse is assigned to care for several clients who are postoperative. The nurse should identify that the client taking which of the following medications is at risk for delayed wound healing?
Prednisone to treat persistent arthritis exacerbations
A nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and/or minerals should the nurse plan to increase in the client's diet?
Vitamin C and zinc
A nurse is reinforcing discharge teaching with a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?
a nurse will show me how to care for my wound
A nurse is assisting with the care of a client who is 2 days postoperative. Which of the following findings should alert the nurse that the client is developing an infection ?
erythema at the incision site
A nurse in an urgent care clinic is caring for a client who has a snakebite on her arm. Which of the following actions should the nurse take?
immobilize the limb at the level of the heart
A nurse is assisting with planning care for a client who has deep partial- thickness and full-thickness thermal burns over 40% of his total body surface. The client is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan?
initiate range of motion exercises
A nurse is contributing to the plan of care for a client with COPD who requires continuous oxygen therapy and is being discharged to return home. Which of the following referrals should the nurse recommend?
social worker
