The nurse is preparing to change the dressing on a client's ...

[james9437]

The nurse is preparing to change the dressing on a client's postoperative wound. Place in order the steps the nurse should perform when removing the soiled dressing.
 
  1. Assess the location, type, and odor of wound drainage.
  2. Remove the outer dressing.
  3. Discard the under dressing in a moisture-proof bag, and remove and discard gloves.
  4. Remove the under dressing.
  5. Apply clean gloves.
  6. Place the soiled dressing in a moisture-proof bag.

Question 2

During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do?
 
  1. Coach the client to deep-breathe and cough.
  2. Restrict fluids.
  3. Remind the client to perform leg exercises.
  4. Maintain on bed rest.

[anyusername12131]

Answer to Question 1

Correct Answer: 5, 2, 6, 4, 1, 3
Rationale 1: Once the under dressing is removed, the nurse should assess the location, type, and odor of any wound drainage.
Rationale 2: The nurse should then remove the outer dressing.
Rationale 3: The nurse should then discard the under dressing in a moisture-proof bag and remove and discard the gloves.
Rationale 4: The nurse should next remove the under dressing.
Rationale 5: The nurse first should apply clean gloves.
Rationale 6: The nurse should place the soiled outer dressing in a moisture-proof bag.

Answer to Question 2

Correct Answer: 1
Rationale 1: The reduction of breath sounds could indicate the pooling of secretions in the lower lobes. The nurse should coach the client to deep-breathe and cough.
Rationale 2: Restricting fluids could cause the pulmonary secretions to thicken, making them more difficult for the client to cough and remove.
Rationale 3: Leg exercises will not improve breath sounds.
Rationale 4: Bed rest will not improve the client's breath sounds.

[james9437]

Excellent

[aliotak]

Gracias!