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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Indirect lighting aids visual impairment, not hearing loss, where attention-getting is key. Assuming lighting is relevant risks ineffective communication, potentially frustrating the client, critical to avoid in ensuring clear, respectful interaction for clients with total hearing loss in care settings.

Choice B reason: Speech therapists address speech, not hearing loss communication, where attention-getting is essential. Assuming therapist collaboration is primary risks overlooking direct communication strategies, critical to prevent in ensuring effective, tailored interaction for clients with total hearing loss in healthcare settings.

Choice C reason: Getting the client’s attention before speaking (e.g., tapping or waving) ensures effective communication for total hearing loss, facilitating lip-reading or sign language. This is critical for clarity, promoting inclusion, and ensuring accurate information exchange, essential for care delivery in hearing-impaired clients.

Choice D reason: Using a loud tone is ineffective for total hearing loss, where visual cues are needed. Assuming loudness helps risks miscommunication, potentially isolating the client, critical to avoid in ensuring respectful, effective communication strategies for clients with complete hearing loss in care.

A. Use an electric razor when shaving while taking this medication. B. Avoid taking this medication with milk products. C. This medication can cause back pain. D. Avoid prolonged exposure to sunlight while taking this medication.

Correct Answer is A

Explanation

Choice A reason: Using an eight electric razor reduces bleeding risk in clients on warfarin, an anticoagulant that increases bleeding tendency, critical for safety. This instruction prevents cuts, essential for minimizing hemorrhage, supporting adherence, and ensuring safe daily activities in clients managing anticoagulation therapy.

Choice B reason: Milk products do not interact with warfarin; consistent vitamin K intake is key. Assuming milk avoidance is needed risks unnecessary dietary restriction, potentially affecting nutrition, critical to avoid in ensuring accurate dietary education for clients on warfarin therapy.

Choice C reason: Back pain is not a common warfarin side effect; bleeding is the primary concern. Assuming back pain is related risks misinforming the client, potentially causing unnecessary worry, critical to prevent in ensuring accurate education and safety for clients on anticoagulation therapy.

Choice D reason: Sunlight exposure does not significantly affect warfarin; photosensitivity is unrelated. Assuming sunlight avoidance is needed risks unnecessary lifestyle restrictions, critical to avoid in ensuring accurate teaching, focusing on bleeding precautions, and supporting safe warfarin use in clients requiring anticoagulation.

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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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