A nurse is completing a dressing change on a client who has a surgical wound drain. Which of the following actions should the nurse take?

Use a separate, sterile swab for each stroke when cleaning the wound.

First clean the drain site and then clean the incision.

Don clean gloves before cleaning the wound.

Cut a 4 x 4 piece of gauze to place around the drain site.

Answer and Explanation

The Correct Answer is A

When completing a dressing change on a client who has a surgical wound drain, the nurse should use a separate, sterile swab for each stroke when cleaning the wound. This helps to prevent the spread of infection and ensures that the wound is properly cleaned.

Option b is incorrect because the nurse should first clean the incision and then clean the drain site.

Option c is incorrect because the nurse should don sterile gloves before cleaning the wound.

Option d is incorrect because the nurse should not cut a 4 x 4 piece of gauze to place around the drain site; instead, the nurse should use a pre-cut drain sponge.

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Correct Answer is A

Explanation

When a hospice nurse is visiting a client who has terminal cancer, the statement "I miss him so much already" by the client's partner should be recognized as an indication of anticipatory grief. Anticipatory grief is the grief that occurs before a loss and can include feelings of sadness, longing, and missing the person who is dying.

Option b is incorrect because anger is a common emotion during the grieving process but does not necessarily indicate anticipatory grief.

Option c is incorrect because planning for the future does not necessarily indicate anticipatory grief.

Option d is incorrect because not discussing funeral arrangements does not necessarily indicate anticipatory grief.

A. Change the PN infusion bag every 48 hours. B. Prepare the client for a central venous line. C. Administer the PN and fat emulsion separately. D. Obtain a random blood glucose daily.

Correct Answer is B

Explanation

Parenteral nutrition (PN) with high concentrations of dextrose, such as 20%, requires a central venous line for administration to prevent damage to peripheral veins. Therefore, preparing the client for a central venous line is an appropriate action to include in the plan of care.

a. The PN infusion bag should be changed every 24 hours to reduce the risk of infection.

d. Blood glucose levels should be monitored regularly, but not necessarily daily, as PN can aﬀect blood glucose levels.

c. PN and fat emulsions can be administered together in a single infusion.

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A nurse is completing a dressing change on a client who has a surgical wound drain. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A hospice nurse is visiting a client who has terminal cancer. Which of the following statements by the client's partner should the nurse recognize as an indication of anticipatory grief?

Correct Answer is A

Explanation

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

Correct Answer is B

Explanation

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