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:
Rubbing the puncture site with an alcohol pad is inappropriate. Rubbing the puncture site with an alcohol pad can cause vasoconstriction and make it more difficult to obtain a blood sample.
Choice B Reason:
Applying firm pressure to the puncture site is inappropriate. Applying firm pressure can further reduce blood flow to the puncture site, making it more challenging to collect an adequate blood sample.
Choice C Reason:
Wrapping the client's hand in a warm washcloth is appropriate. Applying a warm compress to the puncture site can help dilate the blood vessels and improve blood flow, making it easier to obtain a sufficient blood sample. This is especially beneficial for older adults who may have reduced blood flow to the extremities.
Choice D Reason:
Having the client raise his hand is inappropriate. Raising the hand may not be as effective as applying a warm washcloth in promoting blood flow to the puncture site. The warm washcloth helps to encourage vasodilation and improve the chances of obtaining an adequate blood sample.
Correct Answer is D
Explanation
Choice Reason:
Occupational Therapist is incorrect. Occupational therapists focus on helping individuals regain or enhance their ability to perform daily activities and tasks. While they might not directly address dysphagia or swallowing concerns, they could assist in modifying the environment or providing adaptive equipment to facilitate eating, such as recommending specialized utensils or adapting seating positions to support safe eating practices.
Choice B Reason:
Physical Therapist is incorrect. Physical therapists primarily concentrate on restoring mobility, strength, and function in individuals who have experienced injuries or illnesses affecting movement. While they might not directly address dysphagia, they could be involved in helping patients with postural adjustments or exercises that indirectly support safe eating and swallowing.
Choice C Reason:
Respiratory Therapist is incorrect. Respiratory therapists specialize in assessing and treating breathing problems and disorders related to the lungs and respiratory system. While they may not focus directly on dysphagia, they can be involved in managing respiratory complications that can arise from aspiration, such as pneumonia. They might assist in suctioning, breathing exercises, or respiratory treatments in cases where aspiration has led to lung issues.
Choice D Reason:
Speech therapists, also known as speech-language pathologists, is correct because it specializes in evaluating and treating communication and swallowing disorders. They work with individuals who have experienced strokes or other conditions affecting swallowing abilities to improve their swallowing function and reduce the risk of aspiration (when food or liquid enters the airway instead of the digestive tract).
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