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 C
Explanation
Explanation
C. Epistaxis
Heparin is an anticoagulant medication used to prevent blood clot formation. One of the potential adverse effects of heparin therapy is bleeding. Epistaxis, or nosebleeds, can be a sign of abnormal bleeding and should be reported to the provider for further evaluation and adjustment of the treatment plan if necessary.
Weight gain in (option A) is not a common adverse effect of heparin. Weight gain can be caused by various factors, but it is not directly related to heparin administration.
Bradycardia (slow heart rate) in (option B) is not a common adverse effect of heparin. Bradycardia can be caused by other factors unrelated to heparin therapy and should be evaluated separately.
Anorexia (loss of appetite) in (option D) is not typically associated with heparin therapy. Anorexia can have various causes, but it is not directly linked to heparin administration.
Therefore, the nurse should report the occurrence of epistaxis (option C) to the healthcare provider as a potential adverse effect of heparin therapy in the client.
Correct Answer is A
Explanation
ECT can cause temporary memory loss, particularly for events occurring around the time of the treatment. The client may experience difficulty remembering details of recent events or conversations. This effect is usually temporary and improves over time.
Neck pain is not a typical adverse reaction to ECT. The procedure itself does not involve manipulation or strain on the neck, and significant neck pain following ECT would be unusual. However, it is essential for the nurse to assess and address any discomfort or pain the client experiences after the procedure.
Voice alteration is not a known adverse reaction to ECT. ECT primarily affects the brain and does not directly impact the vocal cords or voice production.
Tingling of the scalp is not a common adverse reaction to ECT. During the procedure, the client receives a brief electrical stimulus, usually applied through electrodes placed on the scalp. Sensations experienced during the procedure are typically related to the electrical stimulation and are transient.
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