After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

Answer and Explanation

The Correct Answer is C

After removing a dressing that is saturated with sanguineous drainage, it is essential to dispose of it properly to prevent the spread of infection and maintain a safe environment. The dressing should be placed in a designated biohazard container, which is typically red, to signify that the contents are hazardous and require special handling. The red container is specifically used for items contaminated with blood or bodily fluids, ensuring that they are treated as medical waste and disposed of according to health and safety regulations.

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Correct Answer is []

Explanation

The client has a history of chronic obstructive pulmonary disease (COPD) and is experiencing episodes of more forceful coughing. This history increases the risk of aspiration, especially when taking oral medications. Aspiration can occur if the medication is not swallowed properly, leading to potential respiratory complications.

Assess swallowing ability: Given the client’s COPD and increased coughing, assessing the swallowing ability is crucial before administering oral medications to ensure that the client can safely swallow the medication and reduce the risk of aspiration.

Place in Fowler’s position: Placing the client in Fowler’s position (or semi-Fowler's position) promotes proper swallowing and decreases the risk of aspiration. It also helps improve respiratory function and comfort in clients with COPD.

Increased coughing or choking after administration: Monitoring for increased coughing or choking after taking the medication can help identify early signs of aspiration and allow for prompt intervention to prevent respiratory complications.

Level of consciousness: Monitoring the level of consciousness is important as changes in consciousness can affect the client’s ability to swallow properly and increase the risk of aspiration. It helps ensure the client remains alert and responsive.

A. Auscultate bowel sounds in all quadrants. B. Prepare to administer warfarin. C. Assess characteristics of pain. D. Monitor stools for presence of blood. E. Review last partial thromboplastin time results.

Correct Answer is ["A","C","D","E"]

Explanation

A. Auscultating bowel sounds in all quadrants helps assess the extent of gastrointestinal involvement and possible complications.

B. Administering warfarin is not appropriate in this acute situation where there may be active bleeding; instead, the heparin infusion should be stopped.

C. Assessing the characteristics of the pain is crucial for determining the severity and possible source of the gastrointestinal symptoms.

D. Monitoring stools for the presence of blood is essential to confirm gastrointestinal bleeding and the extent of blood loss.

E. Reviewing the last partial thromboplastin time results helps assess the anticoagulation status of the client and the potential need for reversal.

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After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

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