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:
“I understand that you decided not to receive blood products.” This response shows empathy and acknowledges the client's decision without judgment. It respects the client's autonomy and decision-making capacity.
Choice B Reason:
“Not receiving blood will slow down your memory.” This statement introduces a potential consequence that may not be accurate or relevant to the client's decision. It is important to provide information, but scare tactics or inaccurate statements may not be helpful.
Choice C Reason:
“Why are you refusing to receive blood products?” While understanding the client's rationale is essential, the initial response should convey empathy and acceptance. Asking why may be appropriate later in the conversation, but starting with understanding is crucial.
Choice D Reason:
“You need to talk with your doctor about this.” While involving the doctor is important, it's essential to address the client's feelings and decisions directly. The nurse can play a supportive role in facilitating communication between the client and the healthcare team.
Correct Answer is A
Explanation
Choice A Reason:
Questioning the client about allergies before the procedure is appropriate. It is crucial 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 essential 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 appropriate. 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.
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