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 D
Explanation
This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.
Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis and may not meet the client’s elimination needs.
Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis and may not be necessary unless the client has nausea or vomiting.
Choice C is wrong because providing oral care every four hours is not enough to prevent dehydration and dry mouth in a client who has been diaphoretic for the past six hours. The client may need more frequent oral care and fluid intake.
Correct Answer is D
Explanation
This is because assault is the threat of harm or unwanted contact, and battery is the actual physical contact without consent.
If the nurse administers the injection despite the client’s refusal, the nurse is violating the client’s autonomy and right to refuse treatment, and is committing both assault and battery.
Choice A is wrong because malice means having a deliberate intention to harm someone. The nurse may not have malice but may be acting out of ignorance or negligence.
Choice B is wrong because malpractice means a failure to meet a standard of care or conduct that causes injury or damage to a patient.
The nurse may be guilty of malpractice, but this is not the best term to describe the nurse’s action.
Choice C is wrong because negligence means a lack of care or skill that results in harm or injury.
The nurse may be negligent, but this is not the best term to describe the nurse’s action.
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