A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?

Rationale:

A. Irrigate the wound using a 10 mL syringe: A 10 mL syringe does not provide enough volume or control for effective wound irrigation. Typically, a 30 to 60 mL syringe with an appropriate catheter or tip is used to deliver a steady, low-pressure stream.

B. Cleanse the insertion site of the drain using a circular motion toward the center: Cleansing should be performed from the center outward in circular motions to avoid dragging contaminants toward the wound or drain site. Cleaning toward the center increases the risk of infection.

C. Cleanse the wound starting at the bottom and moving upward: Wound cleansing should be performed from the least contaminated area to the most contaminated — usually from top to bottom or from the incision line outward. Cleaning from bottom to top can introduce bacteria to cleaner areas.

D. Irrigate the wound with a low-pressure flow of solution: Using a low-pressure irrigation helps to flush out debris and reduce bacterial load without damaging healthy tissue or forcing contaminants deeper into the wound. It is the recommended method for safe and effective wound cleansing.

Rationale:

A. Evaluate the client's ability to help with repositioning: Assessing the client's motor function and ability to assist is essential for planning a safe and effective repositioning strategy. It helps prevent injury to both the client and staff and allows for appropriate use of equipment or assistance.

B. Reposition the client without the use of assistive devices: Clients with impaired mobility due to stroke are at increased risk for injury during movement. Assistive devices should be used as needed to ensure safe and proper repositioning.

C. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a restraint-like situation and may increase fall risk. Only the side rail on the opposite side of movement should be raised for safety during repositioning.

D. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care decisions is important, repositioning schedules are primarily based on clinical needs (e.g., immobility, pressure ulcer prevention), not solely on preference.