Question : Which nursing action will be included when the nurse : 2135504
11. Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a client who has a stage III sacral pressure injury?
a. Administer the ordered PRN oral opioid 30 minutes before the dressing change.
b. Soak the old dressings with sterile saline a few minutes before removing them.
c. Pour sterile saline onto the new dry dressings after the wound has been packed.
d. Apply antimicrobial ointment before repacking the wound with moist dressings.
12. The charge nurse observes a new graduate nurse performing a dressing change on a client with a stage 2 left heel pressure injury. Which of the following actions by the new graduate indicates a need for further education about pressure injury care?
a. Uses a hydrocolloid dressing (DuoDerm) to cover the wound
b. Inserts a sterile cotton-tipped applicator into the pressure injury
c. Irrigates the pressure injury with a 30-mL syringe using sterile saline
d. Cleans the wound with a sterile dressing soaked in half-strength hydrogen peroxide
13. A client arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which of the following actions by the nurse is most appropriate?
a. Elevate the ankle above heart level.
b. Remove the client’s shoe and sock.
c. Apply a warm moist pack to the ankle.
d. Assess the ankle’s range of motion (ROM).
14. The nurse is admitting a client with stage 3 pressure injuries on both heels. Which of the following information obtained by the nurse will have the most impact on wound healing?
a. The client states that the injuries are very painful.
b. The client has had the heel injuries for the last 6 months.
c. The client has several old incisions that have formed keloids.
d. The client takes corticosteroids daily for rheumatoid arthritis.