A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

Partial separation of the upper part of the incisional line.

This is a sign of wound dehiscence, which is a serious complication that occurs when the edges of a surgical incision separate and the underlying tissues are exposed.

Wound dehiscence can lead to infection, bleeding, and evisceration (protrusion of internal organs through the incision). The nurse should report this finding to the provider immediately and cover the wound with a sterile dressing moistened with sterile saline solution.

Choice A is wrong because mild swelling under the sutures near the incisional line is a normal finding in the early stages of wound healing. It does not indicate infection or dehiscence unless accompanied by other signs such as redness, warmth, pain, or purulent drainage.

Choice B is wrong because crusting of exudate on the incisional line is also a normal finding that indicates the formation of a scab.

A scab protects the wound from infection and helps it heal faster. The nurse should not remove the scab unless instructed by the provider.

Choice D is wrong because pink-tinged coloration on the incisional line is another normal finding that shows healthy granulation tissue.

Granulation tissue is new tissue that fills in the wound and helps it close. It is usually pink or red and moist.

The nurse should follow these general tips for postoperative abdominal incision care:

• Always wash your hands before and after touching your incisions.
• Inspect your incisions and wounds every day for signs your healthcare provider has told you are red flags or concerning.
• Look for any bleeding.

If the incisions start to bleed, apply direct and constant pressure to the incisions.

• Avoid wearing tight clothing that might rub on your incisions.
• Try not to scratch any itchy wounds.
• You can shower starting 48 hours after your operation but no scrubbing or soaking of the abdominal wounds in a tub.
• After the initial dressing from the operating room is removed, you can leave the wound open to air unless there is drainage or you feel more comfortable with soft gauze covering the wound.
• Surgical glue (Indermil) will fall off over a period of up to 2-3 weeks. Do not put any topical ointments or lotions on the incisions.
• Do not rub over the incisions with a washcloth or towel.
• No tub baths, hot tubs, or swimming until evaluated at your clinic appointment.

The correct answer is choice b. Using an electronic messaging system to remind clients when to take medications.

Choice A rationale:

Educating clients about contraindications to specific immunizations is an example of primary prevention, which aims to prevent disease before it occurs.

Choice B rationale:

Using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. It helps manage an existing condition (HIV) by ensuring adherence to treatment, thereby preventing complications and improving quality of life.

Choice C rationale:

Providing clients with information about the benefits of exercise is generally considered primary prevention, as it aims to promote overall health and prevent disease.

Choice D rationale:

Helping clients understand health screenings covered by their insurance plans is an example of secondary prevention, which focuses on early detection and treatment of disease.