What type of dressing allows for multiple inspections and changes without disrupting the skin because the tape is left in place?
Tegaderm or Opsite
Abdominal pads held in place with paper tape
Retention
Montgomery straps
The Correct Answer is D
Choice A rationale
Tegaderm or Opsite dressings are transparent and adhesive, allowing for wound inspection without removal, but they do not involve tape that remains in place for multiple changes.
Choice B rationale
Abdominal pads held in place with paper tape would require the tape to be removed and replaced with each dressing change, which can disrupt the skin.
Choice C rationale
The term ‘retention’ is incomplete and does not specify a type of dressing. Retention typically refers to the ability to keep something in place, such as a dressing, but does not imply that the tape remains in place.
Choice D rationale
Montgomery straps are designed with ties that attach to an adhesive base that remains on the skin. This allows the dressing to be changed without removing and reapplying tape, thus preventing skin disruption.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A headache is a nonspecific symptom and can be associated with many conditions. It is not typically indicative of internal hemorrhage, which is more likely to present with hemodynamic changes.
Choice B rationale
While a rising pulse is a sign of internal hemorrhage due to the body’s attempt to maintain cardiac output, the blood pressure would typically fall, not rise, as the blood volume decreases.
Choice C rationale
Lethargy and a falling pulse are signs of decreased cardiac output, but in the case of internal hemorrhage, the blood pressure would usually fall, not rise, due to the loss of blood volume.
Choice D rationale
Restlessness, a rising pulse, and falling blood pressure are classic signs of internal hemorrhage. The body responds to blood loss by increasing heart rate to maintain perfusion, but as volume continues to decrease, blood pressure falls.
Correct Answer is A
Explanation
Choice A rationale
The nurse’s first priority should always be to assess the patient’s condition. In the context of NPWT, this means checking for any complaints or problems in the wound area. This assessment helps to ensure that the NPWT is not causing additional issues and that the wound is healing as expected.
Choice B rationale
While it is important to check the settings on the NPWT unit to ensure it is functioning correctly, this is not the first priority. The patient’s well-being and response to treatment take precedence over equipment checks.
Choice C rationale
Documentation is a critical part of patient care, but it comes after patient assessment and any necessary interventions. It serves to record the patient’s status and the care provided but is not the immediate priority.
Choice D rationale
Observing the dressing area is part of the overall assessment of the patient and the effectiveness of the NPWT. However, it is not the first action to take. The nurse must first assess the patient for any discomfort or complications before focusing on the dressing itself.
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