A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound.
Which of the following techniques should the nurse use when performing this dressing change?
Remove the tape by pulling from the center of the dressing
Wear sterile gloves to remove the dressing
Clean the wound from the center to the outer edges
Moisten the dressing before removal
The Correct Answer is C
When removing the dressing and cleaning the wound, it is important to start from the center of the wound and work towards the outer edges. This technique helps prevent contamination of the wound by minimizing the risk of dragging bacteria or debris from the surrounding skin into the wound.
The other options listed are not recommended for this specific procedure:
When removing the tape, it is generally recommended to pull it parallel to the skin surface rather than pulling from the center of the dressing. This technique reduces the risk of causing trauma or disrupting the wound.
While it is important to maintain aseptic technique during dressing changes, wearing sterile gloves is not necessary for a wet-to-dry dressing change. Clean, non-sterile gloves are typically sufficient for this procedure, as the dressing material itself is not sterile.
In a wet-to-dry dressing change, the dressing is typically applied moist and allowed to dry over time. Therefore, moistening the dressing before removal is not necessary. The primary goal is to remove the dry dressing, which may adhere to the wound bed, and then clean the wound before applying a fresh dressing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct answer: A
Preschool-aged children (around 3 to 5 years old) have a limited understanding of death compared to older children or adults. They may not fully grasp the finality and permanence of death. They often have a more concrete and literal understanding of death.
A. Believing the death is punishment for bad behavior: Preschool-aged children (typically 3 to 5 years old) often have magical thinking and may believe that their thoughts or actions can cause events to happen. They may think that the death of a parent is a punishment for something they did or thought, reflecting their egocentric view of the world.
B. Recognizing the parent will never wake up: This understanding is more commonly seen in older children who have a more mature grasp of death. Preschool-aged children may not fully comprehend that death is irreversible and permanent.
C. While preschoolers might ask questions about the funeral out of curiosity, this is not the primary way they process or react to the death of a loved one. Their questions are often more about trying to understand what is happening rather than a genuine curiosity about the specifics of the service.
D. Understanding that everyone dies eventually: While preschool-aged children may have some understanding that death is a natural part of life, their comprehension of its full implications is limited. They may not fully grasp the universality of death and its inevitability for all living beings.
Correct Answer is C
Explanation
Dementia is characterized by progressive memory impairment, including difficulty remembering recent events, names, and familiar faces. This memory loss can significantly impact the client's ability to perform daily tasks independently.
While dementia is typically a chronic and progressive condition, it is not uncommon for individuals with dementia to experience acute episodes of confusion, often referred to as "sundowning." These episodes tend to occur in the late afternoon or evening and can involve increased agitation, restlessness, and disorientation.
Illusions are perceptual distortions where a person misinterprets real sensory stimuli. In dementia, individuals may experience illusions, such as mistaking a coat hanging on a door for a person or misinterpreting shadows as threatening figures.
Catatonia, characterized by immobility and unresponsiveness, is not typically associated with dementia. It is more commonly seen in conditions such as schizophrenia or certain neurological disorders.
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