1. The nurse is caring for a patient with a wound. The patient appears

anxious as the nurse is preparing to change the dressing. Which action

should the nurse take?

a. Turn on the television.

b. Explain the procedure.

c. Tell the patient “Close your eyes.”

d. Ask the family to leave the room.

ANS: B

Explaining the procedure educates the patient regarding the dressing

change and involves him in the care, thereby allowing the patient some

control in decreasing anxiety. Telling the patient to close the eyes and

turning on the television are distractions that do not usually decrease a

patient’s anxiety. If the family is a support system, asking support systems

to leave the room can actually increase a patient’s anxiety.

2. The nurse is cleansing a wound site. As the nurse administers the

procedure, which intervention should be included?

Allow the solution to flow from the most contaminated to the least

contaminated.

b. Scrub vigorously when applying noncytotoxic solution to the skin.

c. Cleanse in a direction from the least contaminated area.

d. Utilize clean gauze and clean gloves to cleanse a site.

ANS: C

Cleanse in a direction from the least contaminated area, such as from the

wound or incision, to the surrounding skin. While cleansing surgical or

traumatic wounds by applying noncytotoxic solution with sterile gauze or by

irrigations is correct, vigorous scrubbing is inappropriate and can cause

damage to the skin. Use gentle friction when applying solutions to the skin,

and allow irrigation to flow from the least to the most contaminated area.

3. The nurse is caring for a patient after an open abdominal aortic

aneurysm repair. The nurse requests an abdominal binder and carefully

applies the binder. Which is the best explanation for the nurse to use when 1

teaching the patient the reason for the binder?