The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should:

change the surgical dressing immediately to prevent infection.

outline the area of drainage with a pen and mark it with the date and time.

make a note of the drainage on the worksheet to report it at the end of shift.

reinforce the dressing with clean gauze sponges and tape.

Answer and Explanation

The Correct Answer is B

A. Change the surgical dressing immediately to prevent infection. Changing the dressing immediately is unnecessary unless there is a significant issue, such as excessive drainage or signs of infection. Minor drainage can be observed unless there's a need for further intervention.

B. Outline the area of drainage with a pen and mark it with the date and time. This is the correct action to monitor the drainage over time. By marking the area, the nurse can track whether the drainage increases, stays the same, or decreases, which helps in assessing the wound’s status and effectiveness of the surgical dressing.

C. Make a note of the drainage on the worksheet to report it at the end of shift. While documentation is important, it is essential to monitor the drainage immediately after the initial assessment rather than waiting until the end of the shift.

D. Reinforce the dressing with clean gauze sponges and tape. Reinforcing the dressing may be appropriate if drainage is increasing or if the dressing is inadequate, but marking the area first is necessary for accurate tracking.

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Correct Answer is C

Explanation

A. Apple juice: Apple juice is a clear liquid, which is typically appropriate for a full liquid diet. This item does not need to be removed.

B. Cream of rice cereal: Cream of rice cereal is a proper component of a full liquid diet, as it is soft and liquid in nature.

C. Scrambled eggs: Scrambled eggs are considered a solid food and should not be included in a full liquid diet, which requires all foods to be liquid or semi-liquid.

D. Vanilla yogurt: Vanilla yogurt is a part of a full liquid diet as it is a smooth, creamy consistency that fits the requirements.

A. alternately compress and release to help blood flow through vessels. B. measure pressure in the leg blood vessels and sound an alarm if pressure rises. C. provide gentle continuous compression at low pressure. D. provide firm continuous compression at high pressure.

Correct Answer is A

Explanation

A. Alternately compress and release to help blood flow through vessels. Sequential compression devices (SCDs) work by alternating compression and release to promote venous return, prevent stasis, and reduce the risk of deep vein thrombosis (DVT). This is the correct mechanism of action for these devices.

B. Measure pressure in the leg blood vessels and sound an alarm if pressure rises. SCDs do not measure pressure; they are designed to apply intermittent pressure to the legs to encourage circulation and prevent clot formation.

C. Provide gentle continuous compression at low pressure. SCDs apply intermittent pressure, not continuous pressure. Continuous compression would not be effective in preventing DVT as it does not allow for the periodic relaxation of veins.

D. Provide firm continuous compression at high pressure. SCDs should apply intermittent, not continuous, pressure. High pressure could potentially harm the patient’s circulation and tissues, which is why the compression is designed to be gentle and alternating.

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The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative and has a prescription for a full liquid diet. The nurse enters the client's room to find he has just received a dietary tray. Which of the following items on the tray should the nurse remove?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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