A nurse is setting up a sterile field to perform wound irrigation for a client.
Which of the following actions should the nurse take when pouring the sterile solution?

This action helps the client feel more comfortable and less intimidated by the nurse. It also allows the nurse to observe the client’s swallowing and signs of aspiration more easily.

Choice A is wrong because talking with the client during her feeding can distract her from swallowing properly and increase the risk of aspiration.

The nurse should encourage the client to focus on eating and avoid conversation until the feeding is over.

Choice B is wrong because discouraging the client from coughing during feedings can prevent her from clearing her airway and expelling any food particles that might have entered the trachea.

The nurse should monitor the client for coughing, choking, or changes in voice quality, which are indicators of aspiration.

Choice C is wrong because instructing the client to lift her chin when swallowing can actually make swallowing more difficult and increase the risk of aspiration.

The nurse should instruct the client to tuck her chin when swallowing, which helps close off the trachea and direct food into the esophagus.

The correct answer is choice A. Applying warm compresses to the incision site is anticipated for the client, as it can help reduce swelling and pain.

The other choices are contraindicated for the following reasons:

• Choice B: Maintaining bed rest for 2 days postoperatively is contraindicated, as it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, and pneumonia. The client should be encouraged to ambulate as soon as possible after surgery.
• Choice C: Irrigating indwelling urinary catheter with 50 mL of normal saline is contraindicated, as it can introduce bacteria into the bladder and cause infection. The catheter should be kept patent and draining without irrigation unless there is a specific order from the provider.
• Choice D: Administering enema to relieve constipation is contraindicated, as it can increase the pressure in the pelvic area and cause bleeding or damage to the surgical site. The client should be given stool softeners and laxatives to prevent constipation.
• Choice E: Placing a blanket roll under the client’s knees while in bed is contraindicated, as it can impair blood circulation and cause thrombophlebitis. The client should avoid flexing the knees excessively and elevate the legs slightly when lying down.