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NurseDive Free Nursing Practice Question
A nurse is performing a dressing change for a child and notices that the gauze dressing is adhering to the wound bed. Which of the following actions should the nurse take?
A. Apply firm pressure to the wound base while removing the gauze dressing.
"Apply firm pressure to the wound base while removing the gauze dressing." Applying firm pressure can cause pain and damage the wound bed, delaying healing and increasing the risk of bleeding.
B. Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing.
"Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing." Hydrogen peroxide can damage healthy tissue and delay wound healing. It is not recommended for routine wound care.
C. Continue to remove the gauze dressing by pulling it parallel to the skin.
"Continue to remove the gauze dressing by pulling it parallel to the skin." Removing a dry gauze dressing without moistening it can cause trauma to the wound bed, increasing pain and impeding healing.
D. Saturate the gauze dressing with sterile saline solution prior to removing it.
"Saturate the gauze dressing with sterile saline solution prior to removing it." Moistening the dressing with sterile saline reduces trauma to the wound, prevents tissue damage, and minimizes pain. This method is preferred for atraumatic dressing removal.
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Full Explanation
A. "Apply firm pressure to the wound base while removing the gauze dressing." Applying firm pressure can cause pain and damage the wound bed, delaying healing and increasing the risk of bleeding.
B. "Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing." Hydrogen peroxide can damage healthy tissue and delay wound healing. It is not recommended for routine wound care.
C. "Continue to remove the gauze dressing by pulling it parallel to the skin." Removing a dry gauze dressing without moistening it can cause trauma to the wound bed, increasing pain and impeding healing.
D. "Saturate the gauze dressing with sterile saline solution prior to removing it." Moistening the dressing with sterile saline reduces trauma to the wound, prevents tissue damage, and minimizes pain. This method is preferred for atraumatic dressing removal.
Similar Questions
A nurse is assessing a school-age child who is receiving IV fluids to treat dehydration. Which of the following findings should indicate to the nurse that the fluid replacement therapy has been effective?
A. Capillary refill less than 2 seconds
"Capillary refill less than 2 seconds." A capillary refill time of less than 2 seconds indicates adequate hydration and perfusion, showing that the fluid replacement therapy has been effective.
B. Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)
"Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)." A potassium level of 5.6 mEq/L is elevated (hyperkalemia) and suggests an imbalance, which can result from inadequate kidney function or excessive potassium intake rather than effective rehydration.
C. Voiding less than 1 mL/kg/hr
"Voiding less than 1 mL/kg/hr." Decreased urine output is a sign of persistent dehydration or kidney dysfunction. Effective fluid therapy should restore normal urine output, typically greater than 1 mL/kg/hr in children.
D. Tachycardia
"Tachycardia." Tachycardia is a sign of dehydration. If fluid replacement were effective, heart rate should normalize, not remain elevated.
Full Explanation
A. "Capillary refill less than 2 seconds." A capillary refill time of less than 2 seconds indicates adequate hydration and perfusion, showing that the fluid replacement therapy has been effective.
B. "Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)." A potassium level of 5.6 mEq/L is elevated (hyperkalemia) and suggests an imbalance, which can result from inadequate kidney function or excessive potassium intake rather than effective rehydration.
C. "Voiding less than 1 mL/kg/hr." Decreased urine output is a sign of persistent dehydration or kidney dysfunction. Effective fluid therapy should restore normal urine output, typically greater than 1 mL/kg/hr in children.
D. "Tachycardia." Tachycardia is a sign of dehydration. If fluid replacement were effective, heart rate should normalize, not remain elevated.
A nurse in a clinic is assessing an infant who has diarrhea, is lethargic, and has dry skin. Which of the following findings indicates moderate dehydration?
A. Decreased respiratory rate
"Decreased respiratory rate." Moderate dehydration typically causes tachypnea (increased respiratory rate), not a decreased respiratory rate. This is the body's response to metabolic acidosis caused by fluid loss.
B. Bulging anterior fontanel
"Bulging anterior fontanel." A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel due to fluid loss.
C. Mottled skin
"Mottled skin." Mottled skin can be a sign of severe dehydration or shock, but it is not a definitive indicator of moderate dehydration.
D. Capillary refill 3 seconds
"Capillary refill 3 seconds." A capillary refill time of 2–3 seconds is indicative of moderate dehydration. In severe dehydration, capillary refill would be greater than 4 seconds.
Full Explanation
A. "Decreased respiratory rate." Moderate dehydration typically causes tachypnea (increased respiratory rate), not a decreased respiratory rate. This is the body's response to metabolic acidosis caused by fluid loss.
B. "Bulging anterior fontanel." A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel due to fluid loss.
C. "Mottled skin." Mottled skin can be a sign of severe dehydration or shock, but it is not a definitive indicator of moderate dehydration.
D. "Capillary refill 3 seconds." A capillary refill time of 2–3 seconds is indicative of moderate dehydration. In severe dehydration, capillary refill would be greater than 4 seconds.
A nurse is caring for a child who is to receive the first dose of IV gentamicin. Which of the following actions should the nurse take?
A. Monitor for constipation.
"Monitor for constipation." Constipation is not a common adverse effect of gentamicin. More concerning side effects include nephrotoxicity and ototoxicity.
B. Maintain strict 1&O.
"Maintain strict I&O." Gentamicin can cause nephrotoxicity, so it is essential to monitor intake and output (I&O) closely to assess kidney function and detect early signs of renal impairment.
C. Initiate airborne precautions.
"Initiate airborne precautions." Gentamicin is an antibiotic and does not require airborne precautions. Airborne precautions are used for infections like tuberculosis, measles, and varicella.
D. Encourage bed rest.
"Encourage bed rest." Gentamicin does not require bed rest. However, if the child experiences dizziness due to ototoxicity (another adverse effect), activity may need to be limited.
Full Explanation
A. "Monitor for constipation." Constipation is not a common adverse effect of gentamicin. More concerning side effects include nephrotoxicity and ototoxicity.
B. "Maintain strict I&O." Gentamicin can cause nephrotoxicity, so it is essential to monitor intake and output (I&O) closely to assess kidney function and detect early signs of renal impairment.
C. "Initiate airborne precautions." Gentamicin is an antibiotic and does not require airborne precautions. Airborne precautions are used for infections like tuberculosis, measles, and varicella.
D. "Encourage bed rest." Gentamicin does not require bed rest. However, if the child experiences dizziness due to ototoxicity (another adverse effect), activity may need to be limited.