Difficulty: Medium
Average Score: 93%
Simulated
When measuring the size,depth,and wound tunneling of a client's stage 4 pressure injury what action should the nurse perform first?
Correct answer
A
Rationale
The correct answer is A: Perform hand hygiene. This is the first action the nurse should take to prevent the introduction of infection into the wound. Proper hand hygiene is essential to maintain aseptic technique and reduce the risk of contamination. Assessing the wound bed (B) and measuring the wound width (C) should only be done after ensuring cleanliness. Inserting a swab into the wound (D) is not appropriate as the first step and can introduce pathogens. Therefore, performing hand hygiene is the priority to maintain a safe and clean environment for wound assessment.