When cleansing a wound with a drain, which technique should the practical nurse (PN) use?
Start at the most inflamed area to protect the tissue and promote healing.
Start at the area with the most drainage to avoid infecting other areas.
Start at the drain site to avoid bringing skin bacteria toward the wound.
Start at the clean area several inches away from the drain to avoid contaminating the drain.
The Correct Answer is C
A. Start at the most inflamed area to protect the tissue and promote healing:
Cleansing should progress from least contaminated to most contaminated area.
B. Start at the area with the most drainage to avoid infecting other areas:
This would spread bacteria to cleaner tissue.
C. Start at the drain site to avoid bringing skin bacteria toward the wound:
Drain site is most contaminated; clean outward to prevent contamination of wound.
D. Start at the clean area several inches away from the drain to avoid contaminating the drain:
Would push bacteria toward the more vulnerable drain site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Review the client's vital signs for indications of infection:
Interpreting vital signs requires nursing judgment; not a UAP task.
B. Reassure the client that phantom limb pain is genuine pain:
Providing emotional reassurance is within the PN’s role, not UAP’s.
C. Observe and mark the amount of drainage on the dressing:
Assessment and documentation are PN responsibilities.
D. Empty and measure the drainage in the suction drainage device:
UAPs can perform this task under direction since it is a measurable, routine activity.
Correct Answer is D
Explanation
A. Nausea occurs at the onset of labor:
Nausea may occur but is not the primary reason for NPO status.
B. Emptying time of the stomach is increased in labor:
True, but the main concern is aspiration risk.
C. Blood is shunted from the gut during labor:
Not the major factor for NPO order.
D. There is increased risk of aspiration of emesis:
During labor, anesthesia may be required; delayed gastric emptying increases aspiration risk if vomiting occurs under sedation.
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