A nurse is replacing a dressing for a client who has an abdominal incision with a closed wound drain. Which of the following actions should the nurse take?
Push the skin down while gently removing the tape.
Dry the incision with sterile gauze pads.
Lift the soiled dressing so that the underside faces the client.
Clean around the drain site using horizontal strokes.
The Correct Answer is C
Choice A Reason:
Pushing the skin down while gently removing the tape is incorrect. Pushing the skin while removing tape could cause unnecessary discomfort or trauma to the skin and the incision area. Gentle removal of tape without pulling the skin is recommended to avoid skin injury.
Choice B Reason:
Drying the incision with sterile gauze pads is incorrect. Generally, it's advisable not to dry the incision site with sterile gauze pads as this might cause trauma or disruption to the healing tissues. Patting the incision site dry or allowing it to air dry gently after cleansing is preferable.
Choice C Reason:
Lifting the soiled dressing so that the underside faces the client is correct. Lifting the soiled dressing in a manner that the underside faces the client helps prevent potential contamination of the wound by minimizing contact between the external surface of the dressing and the incision site. This technique reduces the risk of introducing pathogens into the wound during the dressing change.
Choice D Reason:
Cleaning around the drain site using horizontal strokes is incorrect. When cleaning around the drain site, it's typically recommended to use gentle and careful motions without specific emphasis on strokes, as this might cause friction or trauma to the area around the drain. Instead, using gentle circular motions or dabbing around the site is often advised for wound care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A family member is napping in the client's room.
This situation, while not ideal, doesn't involve harm or potential harm to a client, staff, or visitor. It may be addressed through communication and policy reminders but may not require an incident report.
B. A client refuses to eat at mealtime.
Client refusal to eat, while concerning, is not an unexpected or unusual event. It is a common aspect of care, and incident reports are not typically used for such situations.
C. A client's bed alarm is malfunctioning.
This situation involves a malfunction in equipment designed to ensure client safety. It has the potential to compromise the safety of the client and may require an incident report to document the issue and address it appropriately.
D. An assistive personnel is late for the upcoming shift.
Lateness may be an issue that needs addressing, but it's not typically considered an incident requiring a formal incident report. This situation may be addressed through workplace policies and communication.
Correct Answer is B
Explanation
Choice A Reason:
"I'll need to sign a separate consent form first." This statement might indicate a misunderstanding of the process or a belief that signing an advance directive requires a separate consent form, which might not be accurate.
Choice B Reason:
“the opportunity to choose what kind of care I receive while I still can. "This statement reflects the understanding that advance directives allow individuals to make decisions about the type of care they wish to receive while they are still capable of expressing their preferences. Advance directives, such as a living will, enable individuals to outline their healthcare preferences in advance, especially in situations where they might not be able to communicate their wishes later due to illness or incapacity.
Choice C Reason:
“living will, there will be a 1-month delay before it is legally binding. “There typically isn't a standard delay before a living will becomes legally binding. Once the living will be properly completed and witnessed according to legal requirements, it becomes effective.
Choice D Reason:
“have my mind about the care I will receive once I sign my living will." The purpose of a living will be to express one's healthcare preferences in advance. While it's possible to update or change a living will if one's preferences change, signing a living will doesn't inherently mean one can easily alter care preferences once it's in place. Amendments or revocations might require specific legal steps.
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