A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?
Irrigate the wound using a 10-mL syringe.
Irrigate the wound with a low-pressure flow of solution.
Cleanse the wound starting at the bottom and moving upward.
Cleanse the insertion site of the drain using a circular motion toward the center.
The Correct Answer is B
Choice A reason: A 10-mL syringe produces high pressure, risking tissue damage during wound irrigation; low-pressure flow is safer. Assuming a 10-mL syringe is appropriate risks harming the wound, critical to avoid in ensuring gentle, effective irrigation for abdominal incision healing in wound care.
Choice B reason: Irrigating with low-pressure flow (e.g., 35-mL syringe or irrigation system) gently cleanses the abdominal incision, preventing tissue trauma while removing debris. This is critical for infection prevention, promoting healing, and ensuring safe wound care, essential for effective management of surgical incisions in clients.
Choice C reason: Cleansing from bottom to top risks dragging contaminants into the wound; top-to-bottom is standard. Assuming upward cleansing is correct risks infection, critical to prevent in ensuring proper wound hygiene and healing for clients with abdominal incisions during wound care.
Choice D reason: Cleansing drain sites involves circular motion from center outward, not inward, to avoid contamination. Low-pressure irrigation is key for wounds. Assuming inward motion is correct risks infection, critical to avoid in ensuring proper wound and drain care for abdominal incisions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Pork is prohibited in Islam (haram), and including it during Ramadan violates dietary laws, disrespecting the client’s faith. Scheduling meals after sundown respects fasting. Offering pork risks cultural insensitivity, potentially causing distress, critical to avoid in ensuring respectful, patient-centered care during Ramadan.
Choice B reason: Avoiding red meat is not a Ramadan or Islamic requirement; Muslims may consume halal red meat after sundown. Scheduling meals post-sundown is key. Assuming red meat avoidance risks unnecessary dietary restriction, potentially affecting nutrition, critical to prevent in supporting client health during fasting periods.
Choice C reason: Waiting 1 hour after dairy to serve poultry is not an Islamic dietary rule; it may reflect kosher practices. Scheduling meals after sundown aligns with Ramadan fasting. This assumption risks cultural confusion, delaying meals, critical to avoid in ensuring timely nutrition for Muslim clients during Ramadan.
Choice D reason: Scheduling meals after sundown respects Ramadan fasting, when Muslims eat during non-daylight hours (iftar). This ensures nutritional needs are met, critical for health, maintaining cultural sensitivity, and supporting client comfort, aligning with patient-centered care principles for devout Muslims observing Ramadan in healthcare settings.
Correct Answer is B
Explanation
Choice A reason: Discussing preferences for repositioning schedules is secondary to assessing physical ability in stroke clients, who may have hemiplegia. Evaluating ability ensures safety. Assuming preferences are priority risks unsafe repositioning, potentially causing falls, critical to avoid in ensuring safe mobility and care for stroke patients.
Choice B reason: Evaluating the client’s ability to assist with repositioning is critical post-stroke to assess motor function, ensuring safe technique and preventing injury. This informs whether assistive devices or additional staff are needed, essential for reducing fall risk, promoting recovery, and tailoring care to the client’s physical capacity.
Choice C reason: Repositioning without assistive devices is unsafe for stroke clients with potential weakness or paralysis, risking falls or strain. Evaluating ability is priority. Assuming no devices are needed risks injury, critical to prevent in ensuring safe handling, supporting recovery, and maintaining safety in stroke rehabilitation care.
Choice D reason: Raising side rails ensures safety but is secondary to evaluating the client’s ability to assist, which guides repositioning technique. Assuming rails are the first step risks overlooking physical capacity, potentially leading to unsafe repositioning, critical to avoid in preventing falls and ensuring safe care for stroke clients.
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