Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound.
Which of the following techniques should the nurse use when performing this dressing change?
A. Remove the tape by pulling from the center of the dressing
When removing the tape, it is generally recommended to pull it parallel to the skin surface rather than pulling from the center of the dressing. This technique reduces the risk of causing trauma or disrupting the wound.
B. Wear sterile gloves to remove the dressing
While it is important to maintain aseptic technique during dressing changes, wearing sterile gloves is not necessary for a wet-to-dry dressing change. Clean, non-sterile gloves are typically sufficient for this procedure, as the dressing material itself is not sterile.
C. Clean the wound from the center to the outer edges
When removing the dressing and cleaning the wound, it is important to start from the center of the wound and work towards the outer edges. This technique helps prevent contamination of the wound by minimizing the risk of dragging bacteria or debris from the surrounding skin into the wound.
D. Moisten the dressing before removal
In a wet-to-dry dressing change, the dressing is typically applied moist and allowed to dry over time. Therefore, moistening the dressing before removal is not necessary. The primary goal is to remove the dry dressing, which may adhere to the wound bed, and then clean the wound before applying a fresh dressing.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Comprehensive Predictor 2023 - Proctored Exam 1. Take the full exam now
Full Explanation
When removing the dressing and cleaning the wound, it is important to start from the center of the wound and work towards the outer edges. This technique helps prevent contamination of the wound by minimizing the risk of dragging bacteria or debris from the surrounding skin into the wound.
The other options listed are not recommended for this specific procedure:
When removing the tape, it is generally recommended to pull it parallel to the skin surface rather than pulling from the center of the dressing. This technique reduces the risk of causing trauma or disrupting the wound.
While it is important to maintain aseptic technique during dressing changes, wearing sterile gloves is not necessary for a wet-to-dry dressing change. Clean, non-sterile gloves are typically sufficient for this procedure, as the dressing material itself is not sterile.
In a wet-to-dry dressing change, the dressing is typically applied moist and allowed to dry over time. Therefore, moistening the dressing before removal is not necessary. The primary goal is to remove the dry dressing, which may adhere to the wound bed, and then clean the wound before applying a fresh dressing.
Similar Questions
A nurse is reinforcing teaching with a female client about contraception.
Which of the following statements by the client indicates an understanding of the teaching?
A. My partner will use condoms with spermicides.
Using condoms with spermicides can increase the effectiveness of contraception by combining a barrier method with a chemical method to kill sperm.
B. My partner and I will both use a condom during intercourse.
Using two condoms simultaneously (also known as "double bagging") is not recommended because the friction between them can increase the chance of them tearing.
C. I will be able to remove my contraceptive sponge immediately after intercourse.
The contraceptive sponge is a barrier method that is inserted into the vagina before intercourse. It should be left in place for at least 6 hours after intercourse to ensure effectiveness. Removing it immediately after intercourse would decrease its contraceptive effectiveness.
D. My partner and I will use petroleum jelly with latex condoms.
Petroleum jelly, along with other oil-based lubricants, should not be used with latex condoms. Oil-based substances can degrade latex, making the condom more prone to breakage. Water-based lubricants are recommended for use with latex condoms to ensure their integrity and effectiveness.
Full Explanation
A- "My partner will use condoms with spermicides": Using condoms with spermicides can increase the effectiveness of contraception by combining a barrier method with a chemical method to kill sperm.
B. Using two condoms simultaneously (also known as "double bagging") is not recommended because the friction between them can increase the chance of them tearing.
C- "I will be able to remove my contraceptive sponge immediately after intercourse": The contraceptive sponge is a barrier method that is inserted into the vagina before intercourse. It should be left in place for at least 6 hours after intercourse to ensure effectiveness. Removing it immediately after intercourse would decrease its contraceptive effectiveness.
D- "My partner and I will use petroleum jelly with latex condoms": Petroleum jelly, along with other oil-based lubricants, should not be used with latex condoms. Oil-based substances can degrade latex, making the condom more prone to breakage. Water-based lubricants are recommended for use with latex condoms to ensure their integrity and effectiveness.
A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenevermedication changes are prescribed by the client's provider.
The nurse should identify that theclient is using which of the following defense mechanisms?
A. Conversion
Conversion involves the expression of psychological distress or conflict through physical symptoms or ailments. It is not applicable in this scenario since the client's behavior does not involve physical symptoms.
B. Splitting
Splitting is a defense mechanism characterized by a black-and-white thinking pattern, where individuals perceive others or situations as all good or all bad. It does not directly apply in this scenario as the client's behavior is not indicative of splitting.
C. Displacement
Displacement is a defense mechanism in which an individual redirect their emotions or impulses from their original target to a less threatening or safer target. In this scenario, the client yells at the nurse when medication changes are prescribed by the provider. The client may be feeling angry or frustrated about the medication changes but is unable to express those emotions directly towards the provider. Instead, the client displaces those feelings onto the nurse, who may be seen as a safer or more accessible target. The yelling behavior directed at the nurse is a way for the client to release and express their emotions indirectly.
D. Sublimation
Sublimation is a defense mechanism in which an individual channel their unacceptable or potentially harmful impulses into socially acceptable outlets, such as creative or productive activities. It is not evident in this scenario as the client's behavior does not involve transforming the emotions into a more positive or socially acceptable form.
Full Explanation
Explanation:
Displacement is a defense mechanism in which an individual redirect their emotions or impulses from their original target to a less threatening or safer target. In this scenario, the client yells at the nurse when medication changes are prescribed by the provider. The client may be feeling angry or frustrated about the medication changes but is unable to express those emotions directly towards the provider. Instead, the client displaces those feelings onto the nurse, who may be seen as a safer or more accessible target. The yelling behavior directed at the nurse is a way for the client to release and express their emotions indirectly.
Let's briefly discuss the other defense mechanisms mentioned:
A- Conversion: Conversion involves the expression of psychological distress or conflict through physical symptoms or ailments. It is not applicable in this scenario since the client's behavior does not involve physical symptoms.
B- Splitting: Splitting is a defense mechanism characterized by a black-and-white thinking pattern, where individuals perceive others or situations as all good or all bad. It does not directly apply in this scenario as the client's behavior is not indicative of splitting.
D- Sublimation: Sublimation is a defense mechanism in which an individual channel their unacceptable or potentially harmful impulses into socially acceptable outlets, such as creative or productive activities. It is not evident in this scenario as the client's behavior does not involve transforming the emotions into a more positive or socially acceptable form.
A nurse is providing care to a client who is immunocompromised.
Which of the following should the nurse identify as a possible source of infection?
A. Soiled linens are placed on the floor
Placing soiled linens on the floor can lead to cross-contamination and the spread of infectious agents. This can pose a risk to the immunocompromised client, who may be more susceptible to infections.
B. Waste containers are lined with single bags
Lining waste containers with single bags helps contain potentially infectious waste and facilitates proper disposal. This reduces the risk of contamination and exposure to infectious materials.
C. Dampened cloths are used for dusting the area
Using dampened cloths for dusting helps minimize the spread of dust and airborne particles. Dampening the cloth can help capture the dust and prevent it from becoming airborne, reducing the potential for respiratory exposure.
D. Uncapped sharps are put in a puncture-resistant container
Placing uncapped sharps in a puncture-resistant container is an essential practice to prevent needlestick injuries and the transmission of bloodborne pathogens. This ensures safe disposal of sharps and reduces the risk of accidental needlestick injuries to healthcare workers and clients.
Full Explanation
Placing soiled linens on the floor can lead to cross-contamination and the spread of infectious agents. This can pose a risk to the immunocompromised client, who may be more susceptible to infections.
Lining waste containers with single bags helps contain potentially infectious waste and facilitates proper disposal. This reduces the risk of contamination and exposure to infectious materials.
Using dampened cloths for dusting helps minimize the spread of dust and airborne particles. Dampening the cloth can help capture the dust and prevent it from becoming airborne, reducing the potential for respiratory exposure.
Placing uncapped sharps in a puncture-resistant container is an essential practice to prevent needlestick injuries and the transmission of bloodborne pathogens. This ensures safe disposal of sharps and reduces the risk of accidental needlestick injuries to healthcare workers and clients.