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 A

Explanation

Choice A reason: A speech-language pathologist assesses swallowing difficulties, recommending safe feeding techniques for dysphagia, critical for preventing choking and aspiration in older adults. This referral ensures tailored interventions, essential for nutritional safety, reducing pneumonia risk, and supporting quality of life in long-term care settings.

Choice B reason: Occupational therapists address functional skills, not primarily swallowing, which is managed by speech-language pathologists for dysphagia. Assuming their role risks delayed swallowing assessment, potentially increasing choking risk, critical to avoid in ensuring safe eating for older adults in long-term care facilities.

Choice C reason: Respiratory therapists manage breathing issues, not swallowing difficulties, which require a speech-language pathologist for dysphagia. Assuming their involvement risks missing specialized swallowing care, potentially leading to aspiration, critical to prevent in ensuring safe nutrition for older adults with choking risks.

Choice D reason: Social workers address psychosocial needs, not swallowing issues, managed by speech-language pathologists for dysphagia. Assuming their role risks neglecting physical swallowing assessment, increasing choking or aspiration risk, critical to avoid in ensuring safe meal management for older adults in long-term care.

A. I will use a communication board to assess the client’s needs. B. I will use an interpreter when providing client teaching. C. I will use indirect lighting in the client’s room. D. I will collaborate with a speech therapist about the client’s plan of care.

Correct Answer is C

Explanation

Choice A reason: A communication board is for speech or cognitive issues, not visual impairment, where indirect lighting aids vision. Assuming a board is appropriate risks ineffective communication, potentially frustrating the client, critical to avoid in ensuring clear interaction for visually impaired clients in care settings.

Choice B reason: An interpreter is for language barriers, not visual impairment, where indirect lighting enhances visibility. Assuming an interpreter is needed risks misaligned communication strategies, potentially reducing clarity, critical to prevent in ensuring effective teaching and interaction for clients with visual impairments.

Choice C reason: Indirect lighting reduces glare, improving visibility for visually impaired clients, enhancing communication and safety. This understanding is critical for effective interaction, ensuring client comfort, promoting independence, and supporting accurate information exchange, essential for care delivery in clients with visual impairments.

Choice D reason: Collaborating with a speech therapist addresses speech issues, not visual impairment, where indirect lighting is key. Assuming therapist involvement is relevant risks overlooking visual needs, potentially reducing communication efficacy, critical to avoid in supporting visually impaired clients in healthcare settings.

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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 in a long-term care facility is managing the care of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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