img-download-app
img-download-app

A nurse is performing wound care on a 3-day post-operative patient who has undergone exploratory laparotomy with vertical abdominal incision. Which of the following would indicate that the nurse is cleansing the operative site correctly?

Explanation

•Always wipe from the cleanest area to the least cleanest area. In vertical wounds, this is usually from top to bottom and then laterally from the center out. An exploratory laparotomy involves a vertical midline incision into the abdomen. 



•Horizontal wounds must be cleansed from the center of the incision going outward.


•Stab or drain wounds must be cleansed in circular motion.

Visit our website for other NCLEX topics now!
Related questions
A patient goes into cardiac arrest and the nurse initiates CPR. A second nurse responds to the call for help. What should the role of the second nurse be?
Three nurses are discussing a patient's manic symptoms in the cafeteria. The patient's daughter overhears details that she was unaware of and begins to tell the rest of the family. The nurses are guilty of which of the following?
During a disaster, the charge nurse must make room for multiple admissions by discharging patients that are ready. After the nurse selects potential patients for discharge, what should she do next?
A newly diagnosed diabetic asks the nurse how much a unit of insulin is equal to. The nurse responds by explaining that a unit of insulin:
The nurse is administering hydromorphone, 1 mg PO, to a patient with moderate abdominal pain. The nurse can expect the patient's pain to improve after:
A nurse is preparing to administer I.V. fluids that lower serum osmolarity and pull fluid out of the intravascular space. Which fluid should the nurse administer?
The nurse is preparing to administer one unit of packed red blood cells. The nurse should include which of the following interventions?
The nurse administers a PPD test to a co-worker. The nurse will read the test at:
A medical-surgical unit is implementing a floor stock system for medications. Which of the following is an advantage of a floor stock system?
A living will includes which of the following information?
A nurse noticed a nursing assistant entering the room of a patient with tuberculosis. Which action by the nursing assistant demonstrates a need for education on airborne precautions?
A nurse is counseling a 16-year-old boy about health promotion. Which of the following statements, if made by the boy, indicates a need for further intervention?
A nurse manager notices that an increased number of incident reports are completed because of late medication administration around lunch time. What action should the nurse manager take?
A patient is scheduled for surgery later in the day. The surgeon is very busy with another surgery and asks the nurse to obtain informed consent. How should the nurse proceed?
After combining two intravenous medications into a single vial, how should the nurse mix the two solutions?
A newly diagnosed type 1 diabetic requires education on insulin administration. Why should the nurse instruct the patient to rotate insulin injection sites?
When administering a heparin injection, the nurse minimizes pain by choosing what insertion site?
Susan is determining whether her patient has achieved the goals laid out in the care plan. What step of the nursing process is this?
A patient who will undergo plastic surgery tells the nurse she is embarrassed about the surgery and asks the nurse not to tell anyone. How should the nurse respond?
A nursing student administers an I.V. medication but forgets to prime the syringe. The patient then becomes confused and pale. Suspecting an air embolus, what is the appropriate response?
A nurse receives a patient from the operating room after placement of chest tubes. The tubes were placed because of a right lower lobectomy due to a chest injury. The nurse notices a dark, red fluid flowing into the collection chamber amounting to 75 ml when the patient tried to change positions. The nurse should:
Due to an outbreak of E. coli in the community, a public health nurse instructs parents about measures to prevent further occurence, which should include:
A 10-year-old patient is admitted after sustaining a broken arm in a snowmobile accident. Which of the following should be consulted?
You take a verbal order over the phone. What step should be taken to ensure the accuracy of the order?
Which task can be delegated to a nursing assistant?
Based on Maslow's hierarchy of needs, which of the following should be the nurse's first priority?
A nurse is administering PPD tests to other healthcare workers. The nurse inserts the needle at what angle?
A nurse is preparing a blood transfusion for an anemic toddler. Which of the following blood transfusion matches would cause a hemolytic reaction?
A nurse has been informed by the charge nurse that she will be getting a new admission from the emergency room. The nurse is already caring for 5 patients, one who had surgery 3 hours ago and another patient going to surgery later today. What should the nurse do to best manage her assignment?