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. "Refrain from doing any exercises until your symptoms show improvement.": Completely avoiding exercise is not necessary for most people with asthma and can negatively impact cardiovascular health. The goal is to control symptoms so that safe activity is possible.

B. "Use your long-acting beta agonist inhaler after exercise-induced symptoms appear.": Long-acting beta agonists are used for maintenance therapy, not for quick relief. They are not appropriate for immediate symptom control before or after exercise.

C. "Use your short-acting beta agonist inhaler before exercising.": Short-acting beta agonists, such as albuterol, can be taken 5–20 minutes before exercise to prevent exercise-induced bronchospasm. This is the recommended approach for clients with exercise-triggered asthma.

D. "It is safe to exercise if your peak flow meter measures in the red zone.": The red zone indicates severe airway narrowing and poor asthma control, requiring immediate medical attention. Exercise in this state could worsen symptoms and lead to respiratory distress.

A. Perform a sterile dressing change for a client who has an abdominal wound. B. Complete the Glasgow Coma Scale for a client who has an evolving stroke. C. Perform an admission assessment for a client who is scheduled for surgery. D. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus.

Correct Answer is A

Explanation

Rationale:

A. Perform a sterile dressing change for a client who has an abdominal wound: LPNs can perform sterile procedures and wound care on stable clients, making this an appropriate delegated task.

B. Complete the Glasgow Coma Scale for a client who has an evolving stroke: Neurological assessments on unstable or acutely changing clients require RN judgment and should not be delegated to an LPN.

C. Perform an admission assessment for a client who is scheduled for surgery: Admission assessments require comprehensive data collection, interpretation, and nursing judgment, which fall under the RN scope of practice.

D. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus: Discharge teaching for a new condition involves complex education and evaluation of understanding, which are RN responsibilities.

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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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