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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Questioning the client about allergies before the procedure is appropriate. It is essential to assess the client for any allergies, especially to contrast dye, before the procedure. Allergic reactions to contrast dye can range from mild to severe, and prompt identification of potential allergies is crucial to prevent adverse reactions. If the client has a known allergy to the contrast dye, alternative imaging methods or pre-medication may be considered.
Choice B Reason:
Telling the client to increase fluid intake following the procedure is inappropriate. This instruction is relevant post-procedure for the elimination of the contrast dye from the body. However, it is not the priority at this moment, and the client's safety during the procedure takes precedence.
Choice C Reason:
Evaluating the client for claustrophobia is inappropriate. Assessing for claustrophobia is important, especially if the CT scan involves an enclosed space. However, this assessment can typically be conducted in advance of the procedure during the pre-procedure preparations.
Choice D Reason:
Informing the client about the steps of the procedure is inappropriate. Providing information about the procedure is important for the client's understanding and cooperation. However, ensuring the client's safety during the procedure by assessing for potential allergies to the contrast dye comes first.
Correct Answer is C
Explanation
Choice A Reason:
"Opioids will be restricted if your partner develops respiratory distress." This statement might cause unnecessary concern or confusion. While opioid use might be adjusted based on the client's condition and symptoms, framing it in terms of restriction might not be the most appropriate way to communicate about pain management in end-of-life care.
Choice B Reason:
"Encourage your partner to eat three large meals each day." Encouraging large meals might not align with the typical dietary approach for someone in end-of-life care, especially if they have reduced appetite or are unable to eat comfortably. End-of-life care often focuses on providing smaller, more manageable meals based on the individual's preferences and capabilities.
Choice C Reason:
"Assume your partner can hear you, even if they do not respond. “This statement encourages the partner to communicate with their loved one, acknowledging the potential for the person to hear even if they are not responsive. Many studies suggest that hearing may persist even in individuals who are unresponsive or in a comatose state, so speaking to them can provide comfort and connection.
Choice D Reason:
"We will use an electric blanket to keep your partner warm." The use of an electric blanket might not be suitable, as the client's sensitivity to temperature might change in end-of-life care. Other methods, such as blankets or adjusting the room temperature, could be more appropriate to ensure comfort without the risks associated with electric blankets.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today