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: Urine output of 20 mL/hr is below the desired 30 mL/hr during magnesium sulfate therapy, indicating potential toxicity or renal issues, not a therapeutic effect. Absence of eclampsia is the goal. Monitoring for low output risks missing seizure prevention, critical for maternal safety in preeclampsia management.

Choice B reason: Fetal heart rate of 116/min is within normal (110-160/min) but not a direct therapeutic effect of magnesium sulfate, which prevents seizures. Absence of eclampsia is key. Assuming heart rate is the focus risks overlooking maternal neurological status, critical for ensuring seizure prevention in preeclampsia treatment.

Choice C reason: Blood pressure of 150/92 mm Hg, while elevated, is not the primary therapeutic effect of magnesium sulfate, which targets seizure prevention, not hypertension. Absence of eclampsia is priority. Focusing on blood pressure risks neglecting seizure monitoring, critical for maternal safety in preeclampsia management with magnesium.

Choice D reason: Absence of eclampsia (seizures) is the primary therapeutic effect of magnesium sulfate in preeclampsia, stabilizing neuronal excitability, preventing life-threatening convulsions. Monitoring this ensures maternal safety, critical for preventing neurological damage, supporting fetal well-being, and guiding therapy adjustments in high-risk obstetric care.

A. The nurse will ask you to wear protective eyewear during this procedure. B. The nurse will ask you to remove any transdermal patches prior to the procedure. C. You should not have this procedure if you have a tattoo. D. You should not have this procedure if you are allergic to iodine.

Correct Answer is B

Explanation

Choice A reason: Protective eyewear is not required for MRI; removing transdermal patches prevents burns. Assuming eyewear is needed risks misinformation, potentially causing confusion, critical to avoid in ensuring accurate preparation and safety for clients undergoing MRI scans in diagnostic settings.

Choice B reason: Removing transdermal patches before an MRI prevents burns from metallic components, critical for client safety. This instruction ensures proper preparation, reducing injury risk, supporting safe imaging, and adhering to MRI safety protocols, essential for clients undergoing magnetic resonance imaging procedures.

Choice C reason: Tattoos are generally safe for MRI, though rare risks exist; patches are a greater concern. Assuming tattoos contraindicate MRI risks unnecessary restriction, potentially delaying diagnosis, critical to avoid in ensuring accurate preparation and access to imaging for clients with tattoos.

Choice D reason: Iodine allergy is relevant for CT contrast, not MRI, which uses gadolinium; patches are priority. Assuming iodine allergy contraindicates MRI risks misinformation, potentially delaying imaging, critical to prevent in ensuring proper preparation and safety for clients undergoing MRI scans.

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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 assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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