The nurse is performing a dry sterile dressing change for an abdominal wound.
The nurse should use a swab to clean:
From the left to the right across the wound.
From the outer abdomen toward the wound.
In a circular motion around the wound, circling to the outside.
Directly over the wound.
The Correct Answer is C
Choice A rationale:
Cleaning from left to right across the wound can introduce bacteria from the surrounding skin into the wound, which can lead to infection.
Choice B rationale:
Cleaning from the outer abdomen toward the wound can also introduce bacteria from the surrounding skin into the wound.
Choice C rationale:
Cleaning in a circular motion around the wound, circling to the outside, helps to move bacteria away from the wound and reduce the risk of infection.
Choice D rationale:
Cleaning directly over the wound can disrupt the healing process and potentially introduce bacteria into the wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Restlessness, rising pulse, and falling blood pressure are classic signs of shock, which can occur with internal hemorrhage.
Choice B rationale:
Lethargy, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.
Choice C rationale:
Headache, rising pulse, and falling blood pressure could be signs of many conditions, but they are not specific to internal hemorrhage.
Choice D rationale:
Restlessness, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.
Correct Answer is D
Explanation
Choice A rationale:
Massaging bony prominences can lead to tissue ischemia and damage, increasing the risk of pressure injuries.
Choice B rationale:
Repositioning should be done every 2 hours or less for at-risk patients.
Choice C rationale:
Elevating the head of the bed more than 30° can increase shear and friction, leading to pressure injuries.
Choice D rationale:
A high-calorie diet can promote skin integrity and wound healing.
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