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.
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Related Questions
Correct Answer is B
Explanation
The correct answer is that the nurse should turn off the faucet with a clean, dry paper towel when performing hand hygiene at the beginning of his shift. This helps to prevent recontamination of the hands by touching the faucet with clean hands.
Options a, c and d are not correct actions for performing hand hygiene. Rubbing hands together to cause friction for at least 10 seconds, drying hands by working from the forearms down to the fingertips and keeping hands above elbow level when washing are not recommended practices for hand hygiene.
Correct Answer is A
Explanation
When providing change-of-shift report about a client who has shingles, the nurse should include information about the type of transmission-based precautions in place to prevent the spread of infection to other clients and staff. Shingles is caused by the varicella-zoster virus and can be spread through direct contact with the rash.
- The times for routine vital sign measurements may be important information to include in the report, but it is not specific to the client's condition of shingles.
- The client's background health history may be important information to include in the report, but it is not specific to the client's condition of shingles.
- The number of visitors the client had during the shift may be important information to include in the report, but it is not specific to the client's condition of shingles.
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