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 D

Explanation

Choice A reason: TENS units are effective for chronic pain but less practical 4 hours post-knee arthroplasty due to incision sensitivity; cold packs reduce swelling. Assuming TENS is ideal risks discomfort, critical to avoid in early postoperative pain management, ensuring comfort in acute recovery phases.

Choice B reason: Walking 4 hours post-knee arthroplasty is premature, risking strain or bleeding; cold packs are safer. Assuming walking is appropriate risks complications, critical to prevent in early postoperative care, ensuring pain relief and surgical site protection in clients recovering from knee surgery.

Choice C reason: Lidocaine gel is pharmacological, not nonpharmacological, and inappropriate near fresh incisions; cold packs are correct. Assuming gel is nonpharmacological risks misapplication, potentially causing irritation, critical to avoid in ensuring safe, nonpharmacological pain relief in early post-knee arthroplasty recovery.

Choice D reason: Placing a cold pack reduces swelling and pain 4 hours post-knee arthroplasty, a safe nonpharmacological therapy promoting comfort. This is critical for early recovery, minimizing inflammation, supporting healing, and ensuring effective pain management without medications in clients post-total knee arthroplasty.

A. Protamine sulfate. B. Acetylcysteine. C. Flumazenil. D. Naloxone.

Correct Answer is C

Explanation

Choice A reason: Protamine sulfate reverses heparin, not midazolam, a benzodiazepine requiring flumazenil for reversal. Assuming protamine is needed risks ineffective response to oversedation, critical to avoid in ensuring rapid reversal and safety in clients post-moderate sedation with midazolam in surgical settings.

Choice B reason: Acetylcysteine treats acetaminophen overdose, not midazolam, reversed by flumazenil. Assuming acetylcysteine is appropriate risks delayed reversal of sedation, potentially causing respiratory depression, critical to prevent in ensuring safe recovery for clients post-moderate sedation with midazolam in postoperative care.

Choice C reason: Flumazenil reverses midazolam’s benzodiazepine effects, critical for managing oversedation or respiratory depression post-moderate sedation. Having it on hand ensures rapid response, essential for client safety, preventing complications, and supporting recovery in surgical settings using midazolam for procedural sedation.

Choice D reason: Naloxone reverses opioids, not midazolam, a benzodiazepine requiring flumazenil. Assuming naloxone is needed risks ineffective treatment of sedation, potentially prolonging respiratory risks, critical to avoid in ensuring proper reversal and safety in clients post-moderate sedation with midazolam.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 4 hours postoperative following a total knee arthroplasty. The client reports a pain level of 3 on a scale from 0 to 10. Which of the following nonpharmacological pain management therapies should the nurse recommend?

Correct Answer is D

Explanation

A nurse is caring for a client who is postoperative following a procedure that required moderate sedation using midazolam. Which of the following should the nurse have on hand?

Correct Answer is C

Explanation

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