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

A. Personalize the conflict: Making a conflict personal can increase tension and defensiveness among staff. Effective negotiation requires addressing issues objectively rather than targeting individuals.

B. Identify solutions prior to negotiation: Preselecting solutions may limit collaborative problem-solving. Effective negotiation involves exploring options with all parties to reach mutually acceptable outcomes.

C. Attempt to understand both sides of the issue: Understanding each party’s perspective promotes open communication, trust, and collaboration. This approach helps identify common ground and develop solutions that are acceptable to all involved.

D. Focus on how the conflict occurred: Concentrating on past events can create blame and hinder forward-focused problem-solving. Effective negotiation emphasizes current needs and potential solutions rather than dwelling on the cause.

A. A client who is taking warfarin and has started to breastfeed. B. A client who is taking bumetanide and reports an increase in urinary frequency. C. A client who received a Mantoux test 48 hr ago and has an induration. D. A client who is scheduled for a colonoscopy and is taking sodium phosphate.

Correct Answer is A

Explanation

A. A client who is taking warfarin and has started to breastfeed: Warfarin passes into breast milk in very small amounts and is generally considered compatible with breastfeeding. However, the infant’s coagulation status should be monitored, and follow-up with the healthcare provider is appropriate to ensure safety.

B. A client who is taking bumetanide and reports an increase in urinary frequency: Increased urination is an expected pharmacologic effect of loop diuretics like bumetanide. This finding does not require follow-up unless accompanied by other concerning symptoms.

C. A client who received a Mantoux test 48 hr ago and has an induration: A positive Mantoux test requires interpretation by a healthcare provider, but the presence of induration alone is a normal finding that triggers standard follow-up for tuberculosis screening.

D. A client who is scheduled for a colonoscopy and is taking sodium phosphate: Sodium phosphate is commonly used as a bowel prep for colonoscopy. As long as the client follows the prescribed instructions and has no contraindications, this does not require additional follow-up.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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