Which action should the nurse take first when changing a dressing on a wound with a drain?

Correct Answer: A

Rationale: Dressing changes cause pain. Providing analgesics 30 minutes prior (Choice A), per the text, eases discomfort, enhancing patient cooperation. Avoiding drain removal and gloves follow. Gathering supplies is preparatory. Pain management sets the stage for a smooth procedure, making this the correct first action.

Correct Answer: D

Rationale: Goals must be measurable.'Remain free of odorous or purulent drainage' (Choice D), per the text, indicates no infection in an unconscious patient. Stating signs isn't feasible. Family actions (Choices B, C) are interventions, not goals. This outcome reflects infection prevention, making it the correct goal.

Correct Answer: C

Rationale: Wound cleansing prevents contamination spread. Cleansing from the least contaminated area (Choice C), per the text, directs solution outward from the wound to surrounding skin, maintaining sterility. Flowing from most to least contaminated risks infection. Vigorous scrubbing damages tissue, even with noncytotoxic solutions like saline. Clean gauze/gloves are standard but not the key intervention. This method protects healing tissue, aligning with infection control principles, making it the correct inclusion.

Correct Answer: D

Rationale: Tertiary intention involves delayed closure after being left open, unlike primary (immediate closure) or secondary (healing from the bottom up) intention.

Correct Answer: D

Rationale: Enzymatic debridement uses topical agents, not mechanical means like wet-to-dry or whirlpools.