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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

0.8.

To find the answer, you need to use the formula: Dose ordered / Dose available = Volume to administer

In this case, the dose ordered is 250,000 units and the dose available is 300,000 units/mL. So, you need to divide 250,000 by 300,000 and get 0.8333.

Then, you need to round it to one decimal place and get 0.8 mL. Choice A is wrong because it is too low.

If you administer 0.4 mL, you will give only 120,000 units of penicillin G benzathine, which is half of the prescribed dose.

Choice C is wrong because it is too high.

If you administer 1.2 mL, you will give 360,000 units of penicillin G benzathine, which is 44% more than the prescribed dose.

Choice D is wrong because it is also too high.

If you administer 1.6 mL, you will give 480,000 units of penicillin G benzathine, which is almost double the prescribed dose.

The normal range for penicillin G benzathine dosage depends on the type and severity of infection, but it is usually between 50,000 and 2.4 million units per injection.

A. Hemoglobin 15.3 mg/dL. B. Serum Osmolality 265 mOsm/Kg. C. Serum Sodium 134 mEq/L. D. Urine specific gravity 1.025.

Correct Answer is B

Explanation

This indicates that the client has a fluid volume deficit, which is consistent with the signs and symptoms of low urine output, weight gain, irritability, and headache. The normal range for serum osmolality is 275 to 295 mOsm/Kg.

Choice A is wrong because hemoglobin 15.3 mg/dL is within the normal range of 12 to 18 mg/dL and does not correlate with fluid imbalance.

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Which action is appropriate for a nurse to remove a soiled wound dressing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is to receive 250,000 units of benzathine penicillin. G. The medication is available in a vial containing 300,000 units per milliliter. How many milliliters should a nurse administer?

Correct Answer is B

Explanation

The client’s 24-hour urine output is 750 mL and an amber color, oral intake is 1700 mL, and the weight has increased 3 kilograms in 2 days. The client is irritable and states “I have a headache.” Which laboratory value most correlates with these signs and symptoms?

Correct Answer is B

Explanation

Which of these assessment findings should a nurse record as subjective?

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