A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?

Cleanse the insertion site of the drain using a circular motion toward the center.

Irrigate the wound with a low-pressure flow of solution.

Irrigate the wound using a 10-mL syringe.

Cleanse the wound starting at the bottom and moving upward.

Answer and Explanation

The Correct Answer is B

A. Cleanse the insertion site of the drain using a circular motion toward the center: Proper technique involves cleaning from the least contaminated area (the center) outward to the surrounding skin, not toward the center, to prevent introducing pathogens into the wound.

B. Irrigate the wound with a low-pressure flow of solution: Low-pressure irrigation helps remove debris and exudate without damaging tissue or disrupting healing. It is a safe and effective method for cleansing an abdominal incision.

C. Irrigate the wound using a 10-mL syringe: Using a small syringe can create high-pressure flow, which may traumatize tissue. Larger volume syringes (e.g., 30–60 mL) with controlled, low-pressure flow are recommended for wound irrigation.

D. Cleanse the wound starting at the bottom and moving upward: Wound cleaning should proceed from the least contaminated area (top or center of the incision) toward more contaminated areas (periphery) to reduce the risk of introducing bacteria into the wound.

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Correct Answer is C

Explanation

A. "Polyuria can be caused by using antidepressants.": Antidepressants are more commonly associated with urinary retention or hesitancy rather than polyuria, so this statement reflects a misunderstanding of the typical causes.

B. "Polyuria can be caused by enlargement of the prostate gland.": Prostate enlargement usually causes urinary retention, difficulty initiating urination, or nocturia, rather than excessive urine output.

C. "Polyuria can be caused by drinking too much fluid.": Excessive fluid intake increases urine production, which is a common and direct cause of polyuria. This reflects an accurate understanding of one of the typical mechanisms leading to increased urine output.

D. "Polyuria can be caused by trauma to the lower urinary tract.": Trauma is more likely to result in hematuria, pain, or retention, not necessarily polyuria. This statement does not accurately reflect a common cause of excessive urination.

A. Perform an ECG every 12 hr. B. Obtain a cardiac rehabilitation consultation. C. Draw a troponin level every 4 hr. D. Place the client in a supine position while resting.

Correct Answer is B

Explanation

Rationale:

A. Perform an ECG every 12 hr: Frequent ECGs are typically done during the acute phase to monitor for arrhythmias, but by day 3 post-MI, continuous or as-needed monitoring is more appropriate unless new symptoms occur.

B. Obtain a cardiac rehabilitation consultation: Early involvement of cardiac rehab supports gradual activity progression, lifestyle modification, and psychosocial support, improving long-term outcomes after MI.

C. Draw a troponin level every 4 hr: Troponin testing is most useful for diagnosing and trending damage during the first 24 hours; by day 3, levels have usually peaked and are declining.

D. Place the client in a supine position while resting: Supine positioning can increase cardiac workload; a semi-Fowler's position is preferred to reduce venous return and ease breathing.

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A nursery nurse is attending the birth of a post-term infant.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing

and .

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A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?

Nursing Test Bank

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