A charge nurse is observing a newly licensed nurse change a client's wound dressing. Which of the following actions by the newly licensed nurse demonstrates an understanding of safe handling techniques?
Gauze is used to clean the wound from the outside to the center.
The soiled dressing is placed on a nearby table.
Clean gloves are discarded after removing the old dressing.
Sterile supplies are opened prior to removing the old dressing.
The Correct Answer is C
Choice A Reason:
Gauze is used to clean the wound from the outside to the center. This action does not demonstrate safe handling techniques. Wound cleaning should generally proceed from the least contaminated area to the most contaminated area, which is usually from the center of the wound outward, to avoid introducing microorganisms into the wound.
Choice B Reason:
The soiled dressing is placed on a nearby table. Placing the soiled dressing on a nearby table poses a risk of contamination to the surrounding environment and is not considered a safe practice. Soiled dressings should be properly disposed of in a designated biohazard waste container.
Choice C Reason:
This action demonstrates an understanding of infection control. Clean gloves should be discarded after removing the old dressing to prevent transferring any contaminants to the new dressing or sterile supplies.
Choice D Reason:
Sterile supplies should be opened only after the old dressing has been removed and the wound area has been cleaned.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
The client has four new medications is incorrect. While the addition of new medications may require monitoring and adjustment, it does not directly indicate a need for occupational therapy. Medication management is typically addressed by the healthcare provider or pharmacist.
Choice B Reason:
The client has extreme difficulty swallowing is incorrect. This finding suggests dysphagia, which may require intervention from a speech-language pathologist rather than an occupational therapist. Speech-language pathologists specialize in assessing and treating swallowing difficulties.
Choice C Reason:
The client is experiencing dysarthria is incorrect. Dysarthria refers to difficulty in speaking due to weakness or poor coordination of the muscles used for speech. While it may affect communication and daily activities, it is primarily addressed through speech therapy rather than occupational therapy.
Choice D Reason:
The client requires assistance getting dressed is correct. Difficulty with activities of daily living, such as dressing, bathing, and grooming, is within the scope of occupational therapy. Occupational therapists help clients regain independence in activities of daily living through interventions aimed at improving fine motor skills, coordination, and adaptive strategies. Referring the client to an occupational therapist can help address their dressing needs and promote independence in self-care activities.
Correct Answer is C
Explanation
Choice A Reason:
A client who is at 32 weeks of gestation and has premature rupture of membranes is incorrect. This client is at risk for preterm labor and complications related to premature birth. Management involves monitoring for signs of labor, assessing fetal well-being, and potentially administering medications to prevent preterm labor. This requires obstetrical-specific knowledge and expertise.
Choice B Reason:
A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor is incorrect. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to organs, often the kidneys. Induction of labor in the setting of preeclampsia requires careful monitoring of maternal and fetal well-being, including blood pressure monitoring and fetal heart rate monitoring. Additionally, the use of misoprostol for induction requires understanding of its dosage, administration, and potential side effects, which are specific to obstetrical care.
Choice C Reason:
A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump is correct. This client is postoperative following a Cesarean section and is likely in need of pain management through a PCA pump. Postoperative care after a Cesarean section involves monitoring for signs of complications such as infection, bleeding, and wound healing, as well as managing pain effectively. While nurses with medical-surgical experience may be familiar with PCA pumps, the postoperative care of a cesarean section client involves obstetrical-specific considerations such as uterine monitoring, assessment of lochia (vaginal discharge after childbirth), and breastfeeding support.
Choice D Reason:
A client who has gestational diabetes and is receiving biweekly nonstress tests is incorrect. Gestational diabetes requires monitoring of maternal blood glucose levels and fetal well-being. Nonstress tests are a common method of assessing fetal well-being in pregnancies complicated by conditions such as gestational diabetes. Nurses caring for clients with gestational diabetes need to understand the management of blood glucose levels, dietary considerations, insulin administration if needed, and fetal monitoring techniques. This requires obstetrical-specific knowledge and expertise.
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