A nurse is replacing a dressing for a client who has an abdominal incision with a closed wound drain. Which of the following actions should the nurse take?

Push the skin down while gently removing the tape.

Dry the incision with sterile gauze pads.

Lift the soiled dressing so that the underside faces the client.

Clean around the drain site using horizontal strokes.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Pushing the skin down while gently removing the tape is incorrect. Pushing the skin while removing tape could cause unnecessary discomfort or trauma to the skin and the incision area. Gentle removal of tape without pulling the skin is recommended to avoid skin injury.

Choice B Reason:

Drying the incision with sterile gauze pads is incorrect. Generally, it's advisable not to dry the incision site with sterile gauze pads as this might cause trauma or disruption to the healing tissues. Patting the incision site dry or allowing it to air dry gently after cleansing is preferable.

Choice C Reason:

Lifting the soiled dressing so that the underside faces the client is correct. Lifting the soiled dressing in a manner that the underside faces the client helps prevent potential contamination of the wound by minimizing contact between the external surface of the dressing and the incision site. This technique reduces the risk of introducing pathogens into the wound during the dressing change.

Choice D Reason:

Cleaning around the drain site using horizontal strokes is incorrect. When cleaning around the drain site, it's typically recommended to use gentle and careful motions without specific emphasis on strokes, as this might cause friction or trauma to the area around the drain. Instead, using gentle circular motions or dabbing around the site is often advised for wound care.

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Correct Answer is A

Explanation

Choice A Reason:

"Call me so that I can help you change your position." This response offers practical assistance and comfort to the client. Repositioning can sometimes alleviate discomfort associated with breathing difficulties, and the nurse can offer guidance or physical help to adjust the client's position for improved comfort.

Choice B Reason:

"Try to close your eyes and get some sleep." This response doesn't directly address the client's immediate concern about difficulty breathing and may not offer practical help.

Choice C Reason:

"It is common for breathing to become more difficult as time goes on." While this statement acknowledges the situation, it might not provide the client with actionable guidance or support on how to manage the difficulty in breathing.

Choice D Reason:

"Therapy choices are limited for clients who do not want resuscitation." This response might be interpreted as dismissive or unrelated to the client's immediate needs, focusing more on the DNR order rather than addressing the current concern about breathing difficulties.

A. To an insurance agency in regard to a life insurance policy B. To a medical interpreter service on behalf of a client C. To a family member when the client is not available D. To an employer for a pre-employment screening

Correct Answer is B

Explanation

Choice A Reason:

To an insurance agency in regard to a life insurance policy . This situation is incorrect. Generally, disclosure of health information to an insurance agency requires the client's written consent.

Choice B Reason:

To a medical interpreter service on behalf of a client. This situation is correct. In healthcare settings, it is generally acceptable to share limited health information with a medical interpreter service to facilitate communication with the client, especially if the client has limited proficiency in the primary language spoken in the healthcare setting. The interpreter is bound by confidentiality rules similar to healthcare providers.

Choice C Reason:

To a family member when the client is not available. This situation is incorrect. Disclosing health information to a family member typically requires the client's consent unless there are specific circumstances, such as emergencies, where the healthcare provider may need to act in the best interest of the client.

Choice D Reason:

To an employer for a pre-employment screening. This situation is incorrect. Disclosing health information to an employer typically requires the client's written consent. Employment-related health information is usually protected by privacy laws.

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A nurse is replacing a dressing for a client who has an abdominal incision with a closed wound drain. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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