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
The nurse should obtain a sputum culture specimen before administering any antibiotics to the client with bacterial pneumonia.
This is because the sputum culture can help identify the causative organism and the appropriate antibiotic therapy.
Administering antibiotics before obtaining the sputum culture can alter the results and lead to ineffective treatment.
Choice B is wrong because azithromycin is an antibiotic that should be given after obtaining the sputum culture.
Choice C is wrong because coughing and deep breathing are important interventions to promote airway clearance and gas exchange, but they are not the priority actions for this client.
Choice D is wrong because offering clear liquids can help prevent dehydration and thin secretions, but they are not the most urgent action for this client.
Normal ranges for blood urea nitrogen (BUN) are 7 to 20 mg/dL and for creatinine are 0.6 to
1.2 mg/dL.
Elevated levels of these substances can indicate renal impairment, which can be a complication of bacterial pneumonia.
The nurse should monitor these levels and report any abnormalities to the health care provider.
Correct Answer is C
Explanation
Tell me about it.” This response by the nurse would best facilitate communication because it acknowledges the client’s emotional state and invites the client to express their feelings.
It also shows empathy and respect for the client.
Choice A is wrong because it does not address the client’s emotional needs or encourage communication.
It also implies that the nurse is uncomfortable with the client’s crying and wants to avoid it. Choice B is wrong because it does not show empathy or support for the client.
It also indicates that the nurse is too busy or unwilling to listen to the client.
Choice D is wrong because it is too vague and does not acknowledge the client’s emotional state.
It also puts the burden on the client to come up with a solution for their problem.
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