A nurse is changing the dry sterile dressing of a client after a colectomy. Which precaution should the nurse take when performing this procedure?
A) Prepare strips of tape before beginning the procedure.
B) Cleanse wound with alcohol or soap.
C) Cleanse the wound from outside to center.
D) Keep the wound as moist as possible.
A
Feedback:
The nurse should prepare strips of tape before beginning the procedure, because it is difficult to tear and apply tape when wearing gloves. The nurse should not use alcohol or soap because they cause drying that may lead to further skin breakdown. Cleansing from outside to center of the wound may introduce microorganisms into the wound; therefore, cleansing should be done from the center of the wound outward. The nurse should not keep the wound moist because moisture promotes growth and multiplication of microorganisms.
You might also like to view...
The client states, "No one will let me eat or drink anything until after my test and it's been 9 hours since I last ate anything!"
While auscultating the client's abdomen the nurse hears frequent bowel sounds. How will the nurse document this finding in the medical record? 1. Borborygmi present. 2. Hypoactive bowel sounds present. 3. Bruit present. 4. Friction rub present.
A client has a patch test done to determine degree of allergic reaction to suspected allergens. After the patches are applied, the nurse should instruct the client to:
1. leave the patches on until they fall off on their own. 2. return in 1 week to have skin reactions assessed. 3. avoid contact with anyone else for 48 hours. 4. return in 48 hours to have the patches removed.
A 50-year-old woman who underwent restrictive/malabsorptive surgery with a biliopancreatic diversion about one year earlier demonstrated a distinct attitude change from previous visits when she arrived at the clinic
Instead of being friendly, she was argumentative with staff and other patients. The nurse reviewed her history and found that she had stopped taking the vitamin and mineral supplements prescribed post surgery. She suspected that the problem was caused by: 1. Vitamin B-3 deficiency that resulted in Pellagra. 2. Vitamin B-6 deficiency that resulted in increased stress. 3. Vitamin D deficiency that results in bone demineralization. 4. Vitamin C deficiency that resulted in wet beri beri.
A client with preexisting conditions states to the nurse, "I took my blood pressure at home and it was high so I have been taking my husband's propranolol (Inderal) for the last week." Based on the client's statement, which preexisting conditions should the nurse be most concerned with?Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
A. Obesity B. Diabetes mellitus C. COPD D. Asthma E. Rheumatoid arthritis