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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Weight loss: Furosemide is a loop diuretic that promotes excretion of excess fluid through urine. A reduction in body weight reflects fluid loss and indicates that the medication is effectively managing fluid volume excess.
B. Decreased inflammation: Furosemide does not have anti-inflammatory properties. While it may reduce edema associated with fluid overload, it does not directly affect inflammatory processes in tissues.
C. Decreased pain: Pain reduction is not a direct effect of furosemide. Any perceived relief might occur secondarily if edema-related pressure is relieved, but it is not a primary measure of medication effectiveness.
D. Increased blood pressure: Furosemide typically lowers blood pressure by reducing intravascular volume. An increase in blood pressure would suggest that fluid overload is not being adequately managed or that another condition is influencing blood pressure.
Correct Answer is B
Explanation
Rationale:
A. “Staff will apply identification bands to my baby after her first bath.": Identification bands are applied immediately after birth to ensure proper identification and prevent abduction, not after the first bath. Waiting could increase safety risks.
B. "I will not publish a public announcement about my baby's birth.": Limiting public announcements, such as on social media, reduces the risk of unwanted attention and potential abduction. This demonstrates understanding of newborn security measures.
C. "I can remove my baby's identification band as long as she is in my room.": Identification bands must remain on the newborn at all times to maintain safety and prevent misidentification or abduction. Removing them is unsafe.
D. "I can leave my baby in my room while I walk in the hallway.": Leaving a newborn unattended, even briefly, increases the risk of abduction and is against safety protocols. Constant supervision or staff assistance is required.
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