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 E

Explanation

The correct answer is that this situation represents false imprisonment. False imprisonment is the unlawful restraint of an individual's freedom of movement. In this case, the nurse placed the client in restraints without obtaining a prescription from the provider or following proper protocol, which constitutes false imprisonment.

Options a, b, c and d are not correct torts in this situation. Invasion of privacy, negligence, assault and battery are all legal terms that refer to diﬀerent types of wrongdoing, but they do not apply to this specific scenario.

A. Each element has a range from one to five points. B. The higher the score, the higher the pressure injury risk. C. The scale measures six elements. D. The client's age is part of the measurement.

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.

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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

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Explanation

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Correct Answer is C

Explanation

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