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.
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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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Protective precautions (also known as reverse isolation) are implemented to protect clients with compromised immune systems from potential pathogens brought in by healthcare providers or visitors. This choice would be appropriate for clients who are highly susceptible to infections, but it's not the primary choice for managing a wound infected with MRSA.
Choice B rationale:
Droplet precautions are utilized for diseases spread by respiratory droplets. MRSA is primarily spread through direct contact with contaminated skin or objects. Therefore, droplet precautions are not the most appropriate choice for this scenario.
Choice C rationale:
Airborne precautions are designed for diseases that spread via small particles suspended in the air, such as tuberculosis. MRSA does not spread through the airborne route, so airborne precautions are not necessary for a wound infection with MRSA.
Choice D rationale:
Contact precautions are the correct choice when dealing with MRSA infections. MRSA is primarily transmitted through direct physical contact or contact with contaminated objects. By implementing contact precautions, the nurse can effectively prevent the spread of the infection to other clients and healthcare workers.
Correct Answer is D
Explanation
Choice A rationale:
Placing the client in a modified Trendelenburg position is not the first intervention for a client with a deep laceration and heavy bleeding. This position involves tilting the patient with the head lower than the feet and is typically used to improve venous return in certain situations, such as hypovolemic shock. However, for a bleeding wound, the priority is to control the bleeding itself.
Choice B rationale:
Applying a tourniquet just above the wound is a drastic measure and is generally not the first intervention for controlling bleeding. Tourniquets are used when direct pressure and other methods are unsuccessful, as they can lead to complications such as tissue damage and ischemia if not used correctly.
Choice C rationale:
Starting two large-bore IV catheters is important for fluid resuscitation in cases of significant bleeding. However, it is not the first intervention. Directly controlling the bleeding takes precedence to prevent further blood loss.
Choice D rationale:
Applying pressure directly to the wound is the correct answer. This is the initial and immediate action to take when dealing with a heavily bleeding wound. Applying pressure helps to stem the bleeding by promoting clot formation and reducing blood loss. It is a vital step in managing the client's condition and preventing further deterioration.
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