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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D, B, A, C
Explanation
When caring for a client who is nauseated and unable to eat after taking an antibiotic, the nurse should first identify possible nursing interventions that address the client's nausea. The nurse should then review the potential benefits and consequences of each intervention. The nurse should determine the probability of intervention-related complications. Finally, the nurse should select an intervention that provides the greatest benefit and least risk to the client.
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.
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