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 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.
Correct Answer is D
Explanation
Choice A reason: Patient-centered care focuses on individual needs, not incident reporting, which aims at system improvement. Quality improvement is correct. Assuming patient-centered care risks misidentifying the competency, potentially overlooking system safety enhancements, critical to avoid in ensuring effective fall prevention strategies in healthcare.
Choice B reason: Informatics involves data management, not directly incident reporting, which supports quality improvement. Assuming informatics is key risks missing the safety focus, potentially neglecting system analysis, critical to prevent in ensuring incident reports contribute to safer care environments post-client falls.
Choice C reason: Evidence-based practice guides clinical decisions, not incident reporting, which drives quality improvement. Assuming evidence-based practice is relevant risks overlooking system safety analysis, critical to avoid in ensuring incident reports address fall risks and enhance care quality in healthcare settings.
Choice D reason: Completing an incident report demonstrates quality improvement by identifying safety issues like falls, enabling system changes to prevent recurrence. This is critical for enhancing care safety, reducing risks, and improving outcomes, aligning with QSEN competencies in fostering safer healthcare environments post-incident.
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