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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Food exchange lists for meal planning from the American Diabetes Association: The ADA provides evidence-based, reliable resources for meal planning that help clients manage blood glucose levels and make informed dietary choices. These lists are tailored for diabetes management.
B. Food label recommendations from the Institute of Medicine: While the IOM provides general nutrition guidelines, they are not specifically designed for diabetes management and may not address individualized meal planning needs for blood glucose control.
C. Diabetes medication information from the Physicians' Desk Reference: The PDR contains medication details but is intended for healthcare professionals, not clients. It may be too technical for patient education purposes.
D. Personal blogs about managing the adverse effects of diabetes medications: Blogs may provide anecdotal information that is not evidence-based and could be inaccurate or misleading, making them an unreliable resource for client education.
Correct Answer is C
Explanation
A. "Polyuria can be caused by using antidepressants.": Antidepressants are more commonly associated with urinary retention or hesitancy rather than polyuria, so this statement reflects a misunderstanding of the typical causes.
B. "Polyuria can be caused by enlargement of the prostate gland.": Prostate enlargement usually causes urinary retention, difficulty initiating urination, or nocturia, rather than excessive urine output.
C. "Polyuria can be caused by drinking too much fluid.": Excessive fluid intake increases urine production, which is a common and direct cause of polyuria. This reflects an accurate understanding of one of the typical mechanisms leading to increased urine output.
D. "Polyuria can be caused by trauma to the lower urinary tract.": Trauma is more likely to result in hematuria, pain, or retention, not necessarily polyuria. This statement does not accurately reflect a common cause of excessive urination.
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