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

A.Age alone is not a reliable or unique identifier. Many clients can share the same age, and this information does not sufficiently confirm an individual’s identity. Using age alone could lead to errors, as it lacks specificity.

B.Room numbers are not reliable for client identification because clients may be moved to different rooms or share rooms with others. Using a room number alone could easily lead to a medication error, as it does not confirm the client’s personal identity.

C.Using a photograph is an acceptable form of client identification, especially in settings where clients may not be able to verbally confirm their identity (e.g., clients with dementia). Photographs, when available, are typically included in the client’s medical records and can help ensure correct patient identification to prevent medication errors.

D.Bed numbers, similar to room numbers, are not unique to an individual and may change or be shared in multi-bed rooms. Relying on a bed number could result in giving medication to the wrong client, which is a significant risk to client safety.

A. The type of transmission-based precautions in place. B. The times for routine vital sign measurements. C. The client's background health history. D. The number of visitors the client had during the shift.

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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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?

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