A nurse is providing teaching to a client who has a prescription for oxygen administration at home. Which of the following statements should the nurse include in the teaching?

Rationale:

A. Crusting of exudate on the incisional line: A small amount of dried exudate forming a crust along the incision is a normal part of the healing process and typically does not indicate infection or complication. It protects the tissue underneath and usually resolves with routine hygiene, so it does not require immediate reporting.

B. Mild swelling under the sutures near the incisional line: Mild localized swelling is expected in the early postoperative period due to inflammation and tissue repair. This is a common finding and generally resolves as healing progresses, making it a normal assessment observation.

C. Partial separation of the upper part of the incisional line: Partial dehiscence is a serious complication that can lead to infection, evisceration, or delayed healing. This finding requires prompt notification of the provider for immediate intervention, which may include wound closure, protective dressing, or surgical management.

D. Pink-tinged coloration on the incisional line: Light pink coloration along the incision indicates normal healing and adequate perfusion of the tissue. It reflects healthy granulation tissue formation and is expected in the early stages postoperatively, so it does not require urgent reporting.

Rationale:

A. Initiate one-to-one observation for the client: One‑to‑one observation is essential for safety when a client expresses risk for self‑harm, but the nurse must first assess the content of the hallucinations to determine the immediacy and severity of the risk. Understanding what the voices are saying guides the urgency of interventions and the level of monitoring required.

B. Turn on soft music to distract the client from hearing voices: Distraction techniques can help clients manage hallucinations, but they are not appropriate as an initial action when the client is reporting commands related to self‑harm. The priority is to gather critical assessment data before attempting coping strategies that may not address imminent danger.

C. Ask the client what they are hearing: Assessing the content, tone, and intent of the hallucinations is the first priority because command hallucinations can pose significant danger. Asking directly helps the nurse determine whether the client has an immediate plan or intent to act, which guides safety precautions and necessary interventions.

D. Refer to the hallucination as if it were real: Reinforcing hallucinations can worsen the client’s disorientation and increase distress. The nurse should maintain therapeutic boundaries by acknowledging the client’s experience without validating the hallucination, while also performing an immediate assessment of the risk of self‑harm.