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 D
Explanation
Choice A reason: Smallpox vaccination is not routine due to eradication; disaster preparedness involves drills. Assuming vaccination is relevant risks misaligned priorities, diverting resources from practical preparedness, critical to avoid in ensuring nurses contribute effectively to community readiness for various disaster scenarios.
Choice B reason: Quarantine for anthrax is specific and reactive, not a primary preparedness activity; drills are broader. Assuming quarantine planning is key risks neglecting comprehensive disaster training, critical to prevent in ensuring nurses are prepared for diverse emergencies through community mock events.
Choice C reason: Assessing disaster types and scopes is typically administrative, not a nurse’s primary role; drills are practical. Assuming assessment is the focus risks overlooking hands-on preparedness, critical to avoid in ensuring nurses gain skills through community drills for effective disaster response.
Choice D reason: Participating in community drills and mock events prepares nurses for disaster response, enhancing skills in triage and coordination, critical for effective emergency management. This ensures readiness, improves response efficiency, and supports community safety, essential for nurses in disaster preparedness roles across various scenarios.
Correct Answer is D
Explanation
Choice A reason: Pork is prohibited in Islam (haram), and including it during Ramadan violates dietary laws, disrespecting the client’s faith. Scheduling meals after sundown respects fasting. Offering pork risks cultural insensitivity, potentially causing distress, critical to avoid in ensuring respectful, patient-centered care during Ramadan.
Choice B reason: Avoiding red meat is not a Ramadan or Islamic requirement; Muslims may consume halal red meat after sundown. Scheduling meals post-sundown is key. Assuming red meat avoidance risks unnecessary dietary restriction, potentially affecting nutrition, critical to prevent in supporting client health during fasting periods.
Choice C reason: Waiting 1 hour after dairy to serve poultry is not an Islamic dietary rule; it may reflect kosher practices. Scheduling meals after sundown aligns with Ramadan fasting. This assumption risks cultural confusion, delaying meals, critical to avoid in ensuring timely nutrition for Muslim clients during Ramadan.
Choice D reason: Scheduling meals after sundown respects Ramadan fasting, when Muslims eat during non-daylight hours (iftar). This ensures nutritional needs are met, critical for health, maintaining cultural sensitivity, and supporting client comfort, aligning with patient-centered care principles for devout Muslims observing Ramadan in healthcare settings.
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