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 C

Explanation

The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element has a range of one to four points, with a total possible score of 23 points. The lower the score, the higher the risk for pressure injury.

Option a is incorrect because each element has a range from one to four points.

Option b is incorrect because the lower the score, the higher the pressure injury risk.

Option d is incorrect because the client's age is not part of the measurement.

A. "I miss him so much already." B. "I am so angry that this is happening to us." C. "We are planning a trip for next spring." D. "We haven't discussed funeral arrangements."

Correct Answer is A

Explanation

When a hospice nurse is visiting a client who has terminal cancer, the statement "I miss him so much already" by the client's partner should be recognized as an indication of anticipatory grief. Anticipatory grief is the grief that occurs before a loss and can include feelings of sadness, longing, and missing the person who is dying.

Option b is incorrect because anger is a common emotion during the grieving process but does not necessarily indicate anticipatory grief.

Option c is incorrect because planning for the future does not necessarily indicate anticipatory grief.

Option d is incorrect because not discussing funeral arrangements does not necessarily indicate anticipatory grief.

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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 teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

Correct Answer is C

Explanation

A hospice nurse is visiting a client who has terminal cancer. Which of the following statements by the client's partner should the nurse recognize as an indication of anticipatory grief?

Correct Answer is A

Explanation

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