A nurse is completing a dressing change on a client who has a surgical wound drain. Which of the following actions should the nurse take?
Use a separate, sterile swab for each stroke when cleaning the wound.
First clean the drain site and then clean the incision.
Don clean gloves before cleaning the wound.
Cut a 4 x 4 piece of gauze to place around the drain site.
The Correct Answer is A
When completing a dressing change on a client who has a surgical wound drain, the nurse should use a separate, sterile swab for each stroke when cleaning the wound. This helps to prevent the spread of infection and ensures that the wound is properly cleaned.
Option b is incorrect because the nurse should first clean the incision and then clean the drain site.
Option c is incorrect because the nurse should don sterile gloves before cleaning the wound.
Option d is incorrect because the nurse should not cut a 4 x 4 piece of gauze to place around the drain site; instead, the nurse should use a pre-cut drain sponge.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Crackles in the lungs indicate that the client is experiencing fluid overload. When there is an excess of fluid in the body, it can accumulate in the lungs and cause crackles. The other
a. Fever is not a sign of fluid overload.
c. Bradycardia (a slow heart rate) is not a sign of fluid overload.
d. Flattened neck veins are not a sign of fluid overload; distended neck veins may be a sign of fluid overload.
Correct Answer is A
Explanation
Decreased judgment is a common sign of sleep deprivation. When a person is sleep deprived, their cognitive function can be impaired, leading to difficulty making decisions and exercising good judgment.
Options b, c, and d are not necessarily indicative of sleep deprivation. Decreased activity can be a sign of many different conditions, including fatigue or depression. Increased reflexes and increased auditory alertness are not commonly associated with sleep deprivation.
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