A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

Provide wound irrigation.

Avoid accidentally removing the drain.

Gather supplies.

Provide analgesic medication as ordered by Provider.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Providing wound irrigation might be necessary during the dressing change, but it is not the first action the nurse should take. First, the nurse should ensure they have all the necessary supplies to prevent interruptions during the procedure.

Choice B rationale:

While avoiding accidentally removing the drain is important, it is not the first action the nurse should take. Ensuring that all supplies are gathered and ready will help facilitate a smooth and organized dressing change.

Choice C rationale:

Gathering supplies is the priority in this situation. Having all the needed supplies readily available ensures that the dressing change can be carried out efficiently and without unnecessary delays.

Choice D rationale:

Providing analgesic medication as ordered by the provider is important for the patient's comfort during the procedure. However, it should not be the first action the nurse takes. First, the nurse should ensure that they have all the necessary supplies to conduct the dressing change safely.

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Correct Answer is D

Explanation

Choice D rationale:

This statement by an assistive personnel (AP) indicates a need for further teaching. Hand hygiene is crucial to prevent the transmission of microorganisms, and it involves both handwashing and the appropriate use of gloves. Changing gloves between clients is important to prevent cross-contamination, but it doesn't replace the need for handwashing. Hands can become contaminated even with the use of gloves, and proper hand hygiene should be practiced before and after glove use.

Choice A rationale:

The statement about using alcohol-based hand products after most client contact is accurate. Alcohol-based hand sanitizers are effective in reducing the number of microorganisms on the hands when soap and water are not readily available. They are especially useful in healthcare settings.

Choice B rationale:

Washing hands before providing client care is a fundamental principle of infection control. It helps remove dirt, debris, and transient microorganisms from the hands, reducing the risk of infection transmission.

Choice C rationale:

The statement about not wearing artificial nails when providing client care is correct. Artificial nails can harbor microorganisms and are challenging to clean thoroughly. They pose an infection risk and are generally not recommended for healthcare workers who provide direct patient care.

A. The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained. B. The primary health care provider tells a client that the nurse "does not know anything.” C. The nurse restrains a client at bedtime because the client gets up during the night and wanders around. D. The nurse tells a client that he will be tied down if he tries to get up from the chair.

Correct Answer is A

Explanation

Choice A rationale:

This situation represents an example of assault. Assault is the threat of bodily harm or unwanted physical contact, which creates an apprehension of fear in the victim. In this case, the laboratory technician's actions of restraining the client's arm against their will for blood drawing without consent is a form of assault as it involves an intentional act causing fear of harm.

Choice B rationale:

While telling a client that the nurse "does not know anything" is unprofessional and disrespectful, it doesn't constitute assault. This scenario is more related to issues of communication and respect rather than a direct threat of physical harm.

Choice C rationale:

Restraining a client at bedtime to prevent wandering is not assault. This scenario might involve ethical considerations and the appropriate use of restraints, but it doesn't meet the legal definition of assault, which involves a threat of physical harm.

Choice D rationale:

Threatening to tie down a client if they try to get up from the chair is an example of assault. This action creates an apprehension of fear in the client by implying a physically harmful act. It's a direct threat that falls under the category of assault.

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A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?

Correct Answer is D

Explanation

A nurse is reviewing unintentional and intentional torts. Which of the following clinical situations would the nurse identify as an example of assault?

Correct Answer is A

Explanation

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