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","D"]
Explanation
The nurse should acknowledge the need for intimacy and value themselves in sexual relationships, ask if sexual experiences cause any kind of physical or emotional discomfort, and discuss any changes in sexual experience or satisfaction since beginning new treatments ordered by care providers.
These actions show respect, empathy, and professionalism towards the client’s sexuality.
Choice A is wrong because waiting for the client to volunteer information about any sexual problems they are having may imply that the nurse is uncomfortable or uninterested in addressing sexuality.
The nurse should initiate the conversation and create a safe and supportive environment for the client to express their concerns.
Correct Answer is C
Explanation
Hand hygiene techniques are the first line of defense in medical asepsis because they prevent the transmission of microorganisms from one person or object to another. Hand hygiene techniques include washing hands with soap and water or using an alcohol-based handrub.
Choice A is wrong because isolation or barrier procedures are not the first line of defense in medical asepsis, but rather a way of preventing the spread of infection to other patients or health care workers when a patient has a known or suspected infection.
Choice b is wrong because the nature of detergent used on the unit is not the first line of defense in medical asepsis, but rather a factor that affects the effectiveness of cleaning and disinfection of surfaces and equipment.
Choice D is wrong because the ventilation system type is not the first line of defense in medical asepsis, but rather a factor that affects the quality of air and the risk of airborne transmission of microorganisms.
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