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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D"]

Explanation

When planning care for a client who has a prescription for extremity restraints on both wrists, the nurse should assess the client's skin temperature and color before applying the restraints to ensure that there is no circulation impairment. The nurse should also ensure that the client's bed is in the lowest position to prevent falls. The restraints should be secured to allow three fingers to slide under them to prevent injury and ensure proper circulation. Bony prominences should be padded before applying the restraints to prevent pressure injuries.

Option e is incorrect because attaching the client's restraints to the bed rail can cause injury if the bed rail is moved or adjusted.

A. Use an extinguisher to put out the fire. B. Pull the fire alarm. C. Close the doors to client rooms. D. Turn oﬀ any electrical equipment in the room.

Correct Answer is B

Explanation

After moving clients to a safe location, the next action the nurse should take is to pull the fire alarm. This will alert others in the building to the presence of a fire and activate the building's fire suppression systems.

Options a, c, and d are not the next actions the nurse should take. Using an extinguisher to put out the fire may be appropriate if the nurse has been trained to do so and if it is safe to do so. Closing the doors to client rooms can help to contain the spread of smoke and fire, but it is not the next action the nurse should take. Turning oﬀ electrical equipment in the room may help to prevent further ignition sources, but it is not the next action the nurse should take.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse enters a client's room and discovers a smoldering fire in the drapes. After moving clients to a safe location, which of the following actions should the nurse take next?

Correct Answer is B

Explanation

A nurse at a long-term care facility is providing change-of-shift report to an oncoming nurse about a client who has shingles. Which of the following information should the nurse include in the report?

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

A nurse is providing teaching to a client who is to self-administer an ophthalmic solution. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is teaching a client who requires maximal support about how to use a two-wheeled walker. Which of the following actions by the client indicates an understanding of teaching?

A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching?

A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client who is nauseated and unable to eat after taking an antibiotic. Identify the steps the nurse should take to address the client's nausea. (Arrange the steps, placing them in the order of performance. Use all the steps.)