A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?

Cleanse the insertion site of the drain using a circular motion toward the center.

Irrigate the wound with a low-pressure flow of solution.

Irrigate the wound using a 10-mL syringe.

Cleanse the wound starting at the bottom and moving upward.

Answer and Explanation

The Correct Answer is B

A. Cleanse the insertion site of the drain using a circular motion toward the center: Proper technique involves cleaning from the least contaminated area (the center) outward to the surrounding skin, not toward the center, to prevent introducing pathogens into the wound.

B. Irrigate the wound with a low-pressure flow of solution: Low-pressure irrigation helps remove debris and exudate without damaging tissue or disrupting healing. It is a safe and effective method for cleansing an abdominal incision.

C. Irrigate the wound using a 10-mL syringe: Using a small syringe can create high-pressure flow, which may traumatize tissue. Larger volume syringes (e.g., 30–60 mL) with controlled, low-pressure flow are recommended for wound irrigation.

D. Cleanse the wound starting at the bottom and moving upward: Wound cleaning should proceed from the least contaminated area (top or center of the incision) toward more contaminated areas (periphery) to reduce the risk of introducing bacteria into the wound.

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Correct Answer is C

Explanation

Rationale:

A. Skin cool to touch: Cool skin is more commonly associated with shock states or severe peripheral vasoconstriction, not with a hypertensive crisis. In hypertensive crisis, the client is more likely to have warm skin due to increased circulation from elevated blood pressure.

B. Jugular vein distention: While jugular vein distention can occur in right-sided heart failure or severe fluid overload, it is not a hallmark manifestation of hypertensive crisis. The acute issue in hypertensive crisis is extreme elevation in blood pressure with end-organ effects.

C. Headache: Severe headache is a common and classic symptom of hypertensive crisis due to sudden, extreme elevations in blood pressure causing increased ICP and cerebral vessel stress. It often signals an urgent need for BP control to prevent complications such as stroke.

D. Weak peripheral pulses: Weak pulses are more often associated with low cardiac output or severe arterial obstruction. In hypertensive crisis, peripheral pulses are typically bounding and strong because of the elevated systemic vascular resistance.

A. "You have the right to refuse the procedure." B. "We can manage your care following the procedure without complications." C. "Your doctor thinks this surgery is necessary." D. "Let me review the procedure so you can understand what is going to happen."

Correct Answer is A

Explanation

A. "You have the right to refuse the procedure.": Clients have the legal and ethical right to refuse treatment at any time, including surgery. Acknowledging this respects the client’s autonomy and supports informed decision-making.

B. "We can manage your care following the procedure without complications.": This statement minimizes the client’s concerns and may be perceived as coercive. It does not address the client’s right to make an informed choice.

C. "Your doctor thinks this surgery is necessary.": Referencing the provider’s opinion without exploring the client’s concerns does not respect the client’s autonomy and may increase anxiety or pressure to comply.

D. "Let me review the procedure so you can understand what is going to happen.": While providing information is helpful, the client has already expressed refusal. This approach may be more appropriate if the client is undecided, but it does not acknowledge their right to decline.

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A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?

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