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    Ati lpn med surg integumentary test proctored exam

    A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take?

    Explanation & Rationale

    A. Loosen the dressing by pulling the tape away from the wound is incorrect because tape should be pulled toward the incision and skin, not away from the wound, to reduce tension on the skin and prevent trauma or disruption of the incision and drain site. B. Open sterile supplies before removing the dressing is incorrect because the nurse should first remove the soiled dressing, assess the wound, and then open sterile supplies. Opening sterile supplies beforehand increases the risk of contamination while the nurse is handling the old dressing. C. Remove the entire dressing at once is incorrect because dressings, especially those with drains, should be removed carefully and gradually to prevent accidental dislodgement of the drain and to minimize pain and skin trauma. D. Don clean gloves to remove the dressing is correct because removal of an old dressing is considered a clean (not sterile) procedure. Clean gloves protect both the nurse and the client from contamination. Sterile gloves are used when applying the new dressing, not when removing the old one.

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