A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound.

Which of the following techniques should the nurse use when performing this dressing change?

Remove the tape by pulling from the center of the dressing

Wear sterile gloves to remove the dressing

Clean the wound from the center to the outer edges

Moisten the dressing before removal

Answer and Explanation

The Correct Answer is C

When removing the dressing and cleaning the wound, it is important to start from the center of the wound and work towards the outer edges. This technique helps prevent contamination of the wound by minimizing the risk of dragging bacteria or debris from the surrounding skin into the wound.

The other options listed are not recommended for this specific procedure:

When removing the tape, it is generally recommended to pull it parallel to the skin surface rather than pulling from the center of the dressing. This technique reduces the risk of causing trauma or disrupting the wound.

While it is important to maintain aseptic technique during dressing changes, wearing sterile gloves is not necessary for a wet-to-dry dressing change. Clean, non-sterile gloves are typically sufficient for this procedure, as the dressing material itself is not sterile.

In a wet-to-dry dressing change, the dressing is typically applied moist and allowed to dry over time. Therefore, moistening the dressing before removal is not necessary. The primary goal is to remove the dry dressing, which may adhere to the wound bed, and then clean the wound before applying a fresh dressing.

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Correct Answer is A

Explanation

Correct answer: A

A.It is important to document the location of the identification tag to ensure proper identification of the body. This is crucial for legal and administrative purposes and helps prevent any potential confusion or misidentification.

B.A copy of the client's advance directivesis an important document for healthcare providers to have during the client's care but is not typically included in the post-mortem documentation. Advance directives are typically stored separately and are more relevant to the client's care while they are alive.

C. Cause of the client's death: Determining and documenting the cause of death is typically the responsibility of the attending physician or medical examiner, not the nurse.

D.The last set of the client's vital signs in (option D) may be relevant during the client's care and treatment but may not be specifically included in the post-mortem documentation. The focus of post-mortem documentation is usually on aspects such as the cause of death, time of death, interventions performed, and any significant findings related to the client's condition or autopsy.

A. "You can apply counterpressure to your back with each position change." B. "You can splint the incision with a pillow when changing positions." C. "You should change positions as little as possible." D. "You should use patterned-paced breathing when changing positions."

Correct Answer is B

Explanation

Splinting the incision with a pillow when changing positions can provide support and help minimize discomfort and pain in clients who have undergone a cesarean birth. It can help reduce strain on the incision site and provide a sense of stability and comfort.

"You can apply counterpressure to your back with each position change" may be helpful for managing back pain, but it does not specifically address the client's request for nonpharmacological interventions to manage pain when changing positions after a cesarean birth.

"You should change positions as little as possible" is not an appropriate response as it does not address the client's need to manage pain when changing positions. Encouraging movement and position changes, along with appropriate support, can aid in recovery and prevent complications such as blood clots and respiratory issues.

"You should use patterned-paced breathing when changing positions" is not specifically related to managing pain when changing positions after a cesarean birth. While breathing techniques can be useful for pain management during labor and certain procedures, it may not be the most effective strategy for managing pain when changing positions post-cesarean.

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A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound.

Which of the following techniques should the nurse use when performing this dressing change?