After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

Answer and Explanation

The Correct Answer is C

After removing a dressing that is saturated with sanguineous drainage, it is essential to dispose of it properly to prevent the spread of infection and maintain a safe environment. The dressing should be placed in a designated biohazard container, which is typically red, to signify that the contents are hazardous and require special handling. The red container is specifically used for items contaminated with blood or bodily fluids, ensuring that they are treated as medical waste and disposed of according to health and safety regulations.

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Correct Answer is C

Explanation

A. Monitoring oxygen saturation is important but secondary to addressing the immediate cause of the cardiac tamponade.

B. Observing for jugular vein distention is relevant but not the priority compared to directly addressing the tamponade.

C. Notifying the healthcare provider to prepare for pericardiocentesis is the most critical intervention. Cardiac tamponade requires immediate decompression to relieve pressure on the heart and restore normal function.

D. Assessing for paradoxical blood pressure can provide additional information but does not address the immediate need for intervention.

A. Acetaminophen 650 mg PO every 6 hours for temperature greater than 101.0° F (38.3° C) B. Start a peripheral IV C. Chest x-ray D. NPO E. Start oxygen 3 L/minute via nasal cannula F. Sputum culture G. Place the client on a cardiorespiratory monitor H. Run 0.9% sodium chloride IV infusion at 150 mL/hour

Correct Answer is ["B","E"]

Explanation

A. Acetaminophen 650 mg PO every 6 hours for temperature greater than 101.0° F (38.3° C): While managing fever is important, it is not as immediate a priority as ensuring the client's breathing and hydration.

B. Start a peripheral IV: Establishing a peripheral IV line is crucial for administering medications and fluids. This is essential for the client's hydration and potential intravenous medication needs.

C. Chest x-ray: Although a chest x-ray is important for diagnosing the cause of the symptoms, it can be done after the client’s immediate needs for oxygen and IV access are addressed.

D. NPO: Keeping the client NPO is necessary, but it doesn't require immediate action compared to oxygenation and IV access.

E. Start oxygen 3 L/minute via nasal cannula: The client is experiencing difficulty breathing, so providing supplemental oxygen is a priority to ensure adequate oxygenation and alleviate respiratory distress.

F. Sputum culture: Obtaining a sputum culture is important for diagnosis, but it can wait until after the client is stabilized with oxygen and IV access.

G. Place the client on a cardiorespiratory monitor: Monitoring the client's cardiac and respiratory status is important, but ensuring oxygenation and IV access takes precedence.

H. Run 0.9% sodium chloride IV infusion at 150 mL/hour: While starting the IV infusion is important, it follows the establishment of the IV line and oxygen administration.

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After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

Patient Data Exhibits Which 2 prescriptions should the nurse complete first?

Correct Answer is ["B","E"]

Explanation

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