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

An idiosyncratic drug effect is an unpredictable and uncommon reaction to a drug that is not related to the dose, the pharmacology, or the patient’s allergy or intolerance. It may be caused by genetic factors, metabolic abnormalities, or interactions with other drugs or substances. An example of an idiosyncratic drug effect is paradoxical agitation or excitement after receiving a sedative.

B. A toxic drug effect is a harmful reaction to a drug that is related to the dose or the pharmacology of the drug. It may cause symptoms such as nausea, vomiting, drowsiness, confusion, or respiratory depression. A toxic drug effect is unlikely to cause agitation after receiving a sedative unless there is an overdose or a drug interaction that increases the level of the sedative in the blood.

C. An allergic drug response is an immunological reaction to a drug that is not related to the dose or the pharmacology of the drug. It may cause symptoms such as rash, itching, swelling, fever, or anaphylaxis. An allergic drug response is unlikely to cause agitation after receiving a sedative unless there is a severe anaphylactic reaction that affects the brain or the circulation.

D. An unexpected drug interaction is a modification of the effect of one drug by another drug or substance that is not predictable based on their pharmacology. It may cause an increase or a decrease in the efficacy or toxicity of one or both drugs. An unexpected drug interaction may cause agitation after receiving a sedative if there is a synergistic effect that enhances the central nervous system stimulation of another drug or substance (such as caffeine, cocaine, or amphetamines) or if there is an antagonistic effect that reduces the central nervous system depression of the sedative (such as flumazenil, naloxone, or physostigmine). However, these interactions are usually known and avoidable by checking the patient’s history and medication list.

A. Tell me how your wife died. B. Have you considered attending a grief group?. C. What has it been like for you since your wife died?. D. You have wonderful children and grandchildren who are very supportive.

Correct Answer is C

Explanation

What has it been like for you since your wife died? This statement shows empathy and invites the client to share his feelings and experiences.

It also acknowledges the client’s loss and validates his grief.

Choice A. Tell me how your wife died.

This statement is too intrusive and may cause the client to feel uncomfortable or defensive. It also focuses on the past event rather than the present situation.

Choice B. Have you considered attending a grief group? This statement is too premature and may imply that the nurse is trying to solve the client’s problem or dismiss his feelings.

It also assumes that the client needs or wants a grief group.

Choice D. You have wonderful children and grandchildren who are very supportive.

This statement is too superficial and may minimize the client’s grief or make him feel guilty. It also shifts the attention away from the client and his wife.

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

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Which statement best documents the situation when a client becomes extremely agitated after receiving a sedative?

Correct Answer is A

Explanation

The nurse talks with a client who is a widower of six years and who misses his wife. What is the best statement by the nurse to encourage the client to express his feelings?

Correct Answer is C

Explanation

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