A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

Provide wound irrigation.

Avoid accidentally removing the drain.

Gather supplies.

Provide analgesic medication as ordered by Provider.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Providing wound irrigation might be necessary during the dressing change, but it is not the first action the nurse should take. First, the nurse should ensure they have all the necessary supplies to prevent interruptions during the procedure.

Choice B rationale:

While avoiding accidentally removing the drain is important, it is not the first action the nurse should take. Ensuring that all supplies are gathered and ready will help facilitate a smooth and organized dressing change.

Choice C rationale:

Gathering supplies is the priority in this situation. Having all the needed supplies readily available ensures that the dressing change can be carried out efficiently and without unnecessary delays.

Choice D rationale:

Providing analgesic medication as ordered by the provider is important for the patient's comfort during the procedure. However, it should not be the first action the nurse takes. First, the nurse should ensure that they have all the necessary supplies to conduct the dressing change safely.

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Correct Answer is ["B","C","E"]

Explanation

Choice A rationale:

The choice "Rectus Femoris" is not the correct answer. The rectus femoris is a muscle located in the thigh and is not a common site for intramuscular injections due to its location and proximity to important structures.

Choice B rationale:

The correct answer is "Vastus Lateralis." Choice B is the correct answer. The vastus lateralis muscle is located on the lateral aspect of the thigh and is a suitable site for intramuscular injections. It is often used in infants and young children or in adults who have limited deltoid muscle mass.

Choice C rationale:

The correct answer is "Dorsogluteal." Choice C is the correct answer. The dorsogluteal muscle, located in the buttocks, has historically been used for intramuscular injections. However, it's important to note that due to the proximity of the sciatic nerve and the potential for incorrect injection technique, this site is used less frequently now.

Choice D rationale:

The choice "Lower abdomen" is not the correct answer. The lower abdomen is not a recommended site for intramuscular injections due to the risk of injuring underlying structures and the potential for subcutaneous injection instead of intramuscular.

Choice E rationale:

The correct answer is "Deltoid." Choice E is the correct answer. The deltoid muscle, located in the upper arm, is commonly used for intramuscular injections, especially for vaccines and smaller medication volumes. However, it has a limited muscle mass and may not be suitable for larger injection volumes.

A. Wash hands for 5 to 10 seconds prior to administering the medication. B. Apply the patch over a non-hairy area within the patient's skin. C. Leave the previous medication patch in place. D. Always ensure that the patient is lying down.

Correct Answer is B

Explanation

Choice A rationale:

Washing hands for 5 to 10 seconds prior to administering medication is indeed an important safety measure, but it is not specifically related to changing or applying a transdermal patch. Hand hygiene is crucial to prevent the spread of infection, but it doesn't directly address the process of applying a patch.

Choice B rationale:

Applying the patch over a non-hairy area within the patient's skin is the correct answer. This is crucial because hair can interfere with the adhesion of the patch, leading to inadequate drug absorption. The rationale behind this is to ensure that the medication is effectively delivered through the skin into the bloodstream without any barriers such as hair. It's also important to choose a site that is clean, dry, and free from cuts or irritation.

Choice C rationale:

Leaving the previous medication patch in place is not recommended. It's essential to remove the old patch before applying a new one to prevent accumulation of the medication and to ensure accurate dosing. Failing to remove the previous patch could lead to an overdose or altered drug effects.

Choice D rationale:

Ensuring that the patient is lying down is not a specific safety measure for changing or applying a transdermal patch. The patient's position doesn't directly impact the effectiveness of the patch or the safety of the application process.

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A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a Medical-Surgical unit is preparing to administer an intramuscular injection to a client. Which of the following sites can the nurse use? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

A Cardiovascular nurse is giving transdermal Fentanyl as per ordered to the patient. What is an important safety measure to take when changing and applying a transdermal patch?

Correct Answer is B

Explanation

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