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
Choice A Reason:
Discarding the vial with the remaining medication in the sharp container is inappropriate. This would result in unnecessary waste of the medication and could lead to increased healthcare costs.
Choice B Reason:
Having another nurse witness the disposal of the remaining medication is inappropriate. Witnessing the disposal is typically required for controlled substances, but in this situation, it's more appropriate to use the remaining medication with appropriate documentation.
Choice C Reason:
Drawing up the remaining 1 mg in a syringe and label it with the contents, date, and time is appropriate. This approach minimizes medication wastage and allows for appropriate documentation of the extra dose drawn up. However, it is crucial to label the syringe clearly with the contents, date, and time to avoid any potential errors or confusion. This labeled syringe can then be used for subsequent doses, as long as it remains within the medication's expiration period and adheres to institutional policies.
Choice D Reason:
Storing the vial in the client's medication drawer for future use is inappropriate. Keeping the vial for future use without appropriate documentation is not recommended, as it may lead to medication errors or confusion.
Correct Answer is C
Explanation
Choice A Reason:
Adding 0.5 mL of diluent to the medication is inappropriate action. Ampules typically contain a single-dose of medication in a liquid form, and dilution is not necessary unless specified by the medication order or manufacturer.
Choice B Reason:
This is not necessary as the tip of the ampule is already sterile before opening. Cleansing after opening does not provide additional benefit and can introduce contaminants.
Choice C Reason:
Using a filter needle to aspirate the medication is inappropriate. Filter needles are not routinely used for administering medication from ample.
Choice D Reason:
This is not appropriate for ampules. Unlike vials, ampules do not require air to be injected. Air injection is necessary only for vials to create pressure, but ampules are opened and medication is drawn directly without the need for air.
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