The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take?

Tell the patient “close your eyes.”

Ask the family to leave the room.

Turn on the television.

Explain the procedure.

Answer and Explanation

The Correct Answer is D

A. Telling the patient to close their eyes may not alleviate their anxiety and does not provide comfort or education.

B. Asking the family to leave could increase the patient's anxiety, especially if the family provides emotional support.

C. Turning on the television may distract the patient, but it doesn't address their anxiety.

D. Explaining the procedure helps reduce anxiety by informing the patient about what to expect, which promotes trust and understanding.

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Correct Answer is D

Explanation

A. A small amount of red drainage is expected immediately after surgery.

B. A shiny, moist stoma indicates healthy tissue and is a normal finding.

C. A rosebud-like appearance of the stoma is expected for a newly created colostomy.

D. A purplish-colored stoma is a sign of compromised circulation and possible necrosis, which requires immediate medical attention.

A. Cover the wound with a moist, sterile gauze dressing B. Check the client's vital signs C. Assess the client's pain level D. Obtain a culver culture and sensitivity of the wound drainage

Correct Answer is A

Explanation

A. The first priority is to protect the wound by covering it with a moist, sterile dressing to prevent further contamination and to stabilize the area until further intervention.

B. Checking the client's vital signs is important, but stabilizing the wound takes precedence.

C. Assessing pain is necessary but not the immediate priority in this situation.

D. A wound culture can be taken later, after covering the wound and ensuring immediate safety.

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The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes a wide separation of the wound edges with light serosanguineous drainage. Which of the following actions should the nurse perform first?

Correct Answer is A

Explanation

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Which of the following is a common risk factor for developing a urinary tract infection (UTI)?

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Which of the following is a common symptom of a urinary tract infection?

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