Which action is appropriate for a nurse to remove a soiled wound dressing?
Saturate dressing thoroughly with saline before removing the dressing.
Remove the dressing from the wound and place in a bag for contaminated items.
Use the old dressing to debride any tissue that is adhered to the wound.
Reinsert the drain if removed with the dressing and let the surgeon know.
The Correct Answer is B
This is the appropriate action because it prevents the spread of infection and maintains a clean environment.
The nurse should also wear gloves and dispose of the bag properly.
Choice A is wrong because saturating the dressing with saline before removing it can cause maceration of the skin and increase the risk of infection. The dressing should be removed gently and carefully, and if it is adhered to the wound, small amounts of sterile saline can be used to loosen it.
Choice C is wrong because using the old dressing to debride any tissue that is adhered to the wound can cause trauma, bleeding, and pain. The nurse should use sterile forceps or cotton- tipped applicators to gently press moistened gauze into the wound surfaces.
Choice D is wrong because reinserting the drain if removed with the dressing can cause injury and infection. The nurse should notify the surgeon immediately if the drain is accidentally removed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
The nurse should use clarifying points made by the patient that are unclear and listening attentively while speaking slowly and clearly as communication techniques when performing a health history.
These techniques help the nurse to gather accurate and comprehensive information from the patient and to establish rapport and trust.
Choice A is wrong because avoiding silences can make the patient feel rushed or interrupted. Silences can be useful to allow the patient to think or express emotions.
Choice D is wrong because sitting approximately two feet away from the client may be too close and invade the personal space of the client. The nurse should maintain a comfortable distance of about 4 to 5 feet from the client, depending on the cultural norms and preferences of the client.
Choice E is wrong because asking the family member to complete the written form may not reflect the true health history of the client. The nurse should obtain the information directly from the client whenever possible, unless the client is unable or unwilling to provide it.
Correct Answer is A
Explanation
The client should not eat anything before the barium enema, as this could interfere with the visualization of the colon. The client should also take a laxative and an enema the night before the test to clear the bowel of any fecal matter.
Choice B is wrong because the client may need to have laxatives to expel the barium after the test, not before. Barium can cause constipation and impaction if not eliminated promptly.
Choice C is wrong because the client will receive the barium prior to the study by rectum, which is correct. The barium is a contrast agent that helps outline the colon on X-rays.
Choice D is wrong because the client will need to lie down during the study while retaining the barium for X-rays, which is correct. The client may also be asked to change positions to allow different views of the colon.
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