Which action is appropriate for a nurse to remove a soiled wound dressing?
Saturate dressing thoroughly with saline before removing the dressing.
Remove the dressing from the wound and place in a bag for contaminated items.
Use the old dressing to debride any tissue that is adhered to the wound.
Reinsert the drain if removed with the dressing and let the surgeon know.
The Correct Answer is B
This is the appropriate action because it prevents the spread of infection and maintains a clean environment.
The nurse should also wear gloves and dispose of the bag properly.
Choice A is wrong because saturating the dressing with saline before removing it can cause maceration of the skin and increase the risk of infection. The dressing should be removed gently and carefully, and if it is adhered to the wound, small amounts of sterile saline can be used to loosen it.
Choice C is wrong because using the old dressing to debride any tissue that is adhered to the wound can cause trauma, bleeding, and pain. The nurse should use sterile forceps or cotton- tipped applicators to gently press moistened gauze into the wound surfaces.
Choice D is wrong because reinserting the drain if removed with the dressing can cause injury and infection. The nurse should notify the surgeon immediately if the drain is accidentally removed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.
The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.
Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.
Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.
Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.
Correct Answer is B
Explanation
This is because acute pain is the most urgent and life-threatening problem for a client with myocardial infarction.
Acute pain indicates ongoing ischemia and tissue damage, which can lead to complications such as heart failure, arrhythmias, or cardiogenic shock. Therefore, relieving pain is the priority nursing diagnosis.
Choice A. Anxiety is wrong because anxiety is not a specific symptom of myocardial infarction and anxiety is due to the discomfort that happens due to activation of the sympathetic pathway which is good for survival.
Choice C. Knowledge deficit is wrong because knowledge deficit is not an immediate problem for a client with myocardial infarction.
Knowledge deficit can be addressed after the acute phase of the condition is over and the client is stable.
Choice D. Nausea and vomiting are wrong because nausea and vomiting are common symptoms of myocardial infarction, but they are not as urgent and life-threatening as acute pain.
Nausea and vomiting can be treated with antiemetics and fluids, but they do not affect the outcome of the condition as much as pain does.
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