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

Explanation

The nurse should respect the client's autonomy and right to make decisions about their own care. Referring the client to hospice care is an appropriate response because it provides the client with support and care in their own home.

Options b, c, and d are not appropriate responses because they do not respect the client's autonomy.

Option b suggests that the client needs to discuss their decision with their family before making a decision, which may not be necessary or desired by the client.

Option c confronts the client with the reality of their illness in a potentially insensitive manner.

Option d suggests that the client is giving up too soon, which may not be an accurate or helpful assessment of the situation.

A. Encourage the client to make choices regarding hygiene. B. Oﬀer the client sips of a citrus ﬂavored soda. C. Position the client supine in bed. D. Suction the client's airway every hour.

Correct Answer is A

Explanation

When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.

Option b is incorrect because oﬀering the client sips of a citrus ﬂavored soda may not be appropriate for all clients and should be based on individual preferences and needs.

Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.

Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.

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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

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