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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is that the client should press the inner corner of their eye after inserting the drops. This technique is called punctal occlusion and it helps to prevent the eye drops from draining into the tear duct and being absorbed by the rest of the body. This can increase the effectiveness of the eye drops and reduce potential side effects.
Options b, c and d are not correct statements by the client that indicate an understanding of how to self- administer an ophthalmic solution. Raising the eyelid up while looking down to insert the drops, keeping eyes closed for 5 minutes after inserting the drops and inserting the drops in the center of each eye are not recommended techniques for self-administering an ophthalmic solution.
Correct Answer is B
Explanation
The correct answer is that the nurse should complete an incident report. An incident report is a formal record of an unexpected event that occurred in a healthcare facility. It is important for the nurse to document the details of the visitor's fall, including the date, time, location and any witnesses. This information can be used to identify and address any safety hazards that may have contributed to the fall.
Options a, c and d are not appropriate actions for the nurse to take in this situation. Administering acetaminophen to the client is not relevant to the visitor's fall. Sending the visitor to the risk management office and documenting the occurrence in the client's medical record are not necessary steps in this situation.
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