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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

The client should not eat anything before the barium enema, as this could interfere with the visualization of the colon. The client should also take a laxative and an enema the night before the test to clear the bowel of any fecal matter.

Choice B is wrong because the client may need to have laxatives to expel the barium after the test, not before. Barium can cause constipation and impaction if not eliminated promptly.

Choice C is wrong because the client will receive the barium prior to the study by rectum, which is correct. The barium is a contrast agent that helps outline the colon on X-rays.

Choice D is wrong because the client will need to lie down during the study while retaining the barium for X-rays, which is correct. The client may also be asked to change positions to allow different views of the colon.

A. The nurse establishes rapport with the client in an inpatient psychiatric setting. B. The nurse documents accurately and honestly in the electronic health record. C. The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. D. The nurse refers to the policy of the inpatient psychiatric setting when uncertain of a standard of care.

Correct Answer is C

Explanation

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.

Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.

Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.

Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.

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Which action is appropriate for a nurse to remove a soiled wound dressing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about preparation for a barium enema. What client statement indicates the client requires further reinforcement of teaching?

Correct Answer is A

Explanation

A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

Correct Answer is C

Explanation

Which interventionshouldthe nurse implement when planning to teach older adult clients?

The nurse is educating a client with insomnia how to promote better sleep. Which interventions should she include for this client? (Select all that apply).

Which physiological change should a nurse expect to observe when assessing an elderly client?

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