Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is completing a dressing change on a client who has a surgical wound drain. Which of the following actions should the nurse take?
A. Use a separate, sterile swab for each stroke when cleaning the wound.
When completing a dressing change on a client who has a surgical wound drain, the nurse should use a separate, sterile swab for each stroke when cleaning the wound. This helps to prevent the spread of infection and ensures that the wound is properly cleaned.
B. First clean the drain site and then clean the incision.
Option b is incorrect because the nurse should first clean the incision and then clean the drain site.
C. Don clean gloves before cleaning the wound.
Option c is incorrect because the nurse should don sterile gloves before cleaning the wound.
D. Cut a 4 x 4 piece of gauze to place around the drain site.
Option d is incorrect because the nurse should not cut a 4 x 4 piece of gauze to place around the drain site; instead, the nurse should use a pre-cut drain sponge.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Fundamentals 2019 with NGN - Proctored Exam 2. Take the full exam now
Full Explanation
When completing a dressing change on a client who has a surgical wound drain, the nurse should use a separate, sterile swab for each stroke when cleaning the wound. This helps to prevent the spread of infection and ensures that the wound is properly cleaned.
Option b is incorrect because the nurse should first clean the incision and then clean the drain site.
Option c is incorrect because the nurse should don sterile gloves before cleaning the wound.
Option d is incorrect because the nurse should not cut a 4 x 4 piece of gauze to place around the drain site; instead, the nurse should use a pre-cut drain sponge.
Similar Questions
A nurse is providing end-of-life care for a client. Which of the following actions should the nurse take?
A. Encourage the client to make choices regarding hygiene.
When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.
B. Offer the client sips of a citrus flavored soda.
Option b is incorrect because offering the client sips of a citrus flavored soda may not be appropriate for all clients and should be based on individual preferences and needs.
C. Position the client supine in bed.
Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.
D. Suction the client's airway every hour.
Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.
Full Explanation
When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.
Option b is incorrect because offering the client sips of a citrus flavored soda may not be appropriate for all clients and should be based on individual preferences and needs.
Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.
Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.
A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?
A. Explain the techniques of esophageal speech.
Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.
B. Schedule a support session for the client.
While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.
C. Determine the client's reading ability.
This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.
D. Review the use of an artificial larynx with the client.
This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.
Full Explanation
A. Explain the techniques of esophageal speech. Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.
B. Schedule a support session for the client. While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.
C. Determine the client's reading ability. This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.
D. Review the use of an artificial larynx with the client. This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.
A nurse is providing end-of-life care for a client. Which of the following actions should the nurse take?
A. Encourage the client to make choices regarding hygiene.
When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.
B. Offer the client sips of a citrus flavored soda.
Option b is incorrect because offering the client sips of a citrus flavored soda may not be appropriate for all clients and should be based on individual preferences and needs.
C. Position the client supine in bed.
Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.
D. Suction the client's airway every hour.
Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.
Full Explanation
When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.
Option b is incorrect because offering the client sips of a citrus flavored soda may not be appropriate for all clients and should be based on individual preferences and needs.
Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.
Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.