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 D

Explanation

A. Weight gain 2.3 kg (5 lb): Mild weight gain can occur with oral contraceptive use and is generally not dangerous. This finding does not require immediate reporting.

B. Frequent nausea: Nausea is a common side effect, especially during the first few months of therapy. While bothersome, it is usually not an urgent concern unless severe or persistent.

C. Breast tenderness: Breast tenderness is a common, mild side effect of oral contraceptives and does not typically indicate a serious problem requiring immediate intervention.

D. Persistent headache: A new, persistent, or severe headache can indicate vascular complications, such as hypertension or increased risk of thromboembolism, which are serious adverse effects of oral contraceptives. This finding requires immediate reporting.

A. The client's lung sounds remain clear during the transfusion. B. The client's blood pressure increases to 140/85 mm Hg following the transfusion C. The client's hemoglobin level increases following the transfusion. D. The client is afebrile during the transfusion.

Correct Answer is C

Explanation

Rationale:

A. The client's lung sounds remain clear during the transfusion: Clear lung sounds indicate the absence of fluid overload or pulmonary complications, which is a safety indicator, but it does not reflect the effectiveness of the transfusion in improving oxygen-carrying capacity.

B. The client's blood pressure increases to 140/85 mm Hg following the transfusion: A sudden rise in blood pressure could indicate fluid overload or a transfusion reaction, not necessarily a positive response to the transfusion.

C. The client's hemoglobin level increases following the transfusion: An increase in hemoglobin indicates that the transfused red blood cells have effectively raised the client’s oxygen-carrying capacity, demonstrating a positive therapeutic response.

D. The client is afebrile during the transfusion: Remaining afebrile indicates the absence of a febrile transfusion reaction, which is a safety measure, but it does not show that the transfusion achieved its therapeutic goal.

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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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Correct Answer is C

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