A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?
Irrigate the wound using a 10-mL syringe.
Irrigate the wound with a low-pressure flow of solution.
Cleanse the wound starting at the bottom and moving upward.
Cleanse the insertion site of the drain using a circular motion toward the center.
The Correct Answer is B
Choice A reason: A 10-mL syringe produces high pressure, risking tissue damage during wound irrigation; low-pressure flow is safer. Assuming a 10-mL syringe is appropriate risks harming the wound, critical to avoid in ensuring gentle, effective irrigation for abdominal incision healing in wound care.
Choice B reason: Irrigating with low-pressure flow (e.g., 35-mL syringe or irrigation system) gently cleanses the abdominal incision, preventing tissue trauma while removing debris. This is critical for infection prevention, promoting healing, and ensuring safe wound care, essential for effective management of surgical incisions in clients.
Choice C reason: Cleansing from bottom to top risks dragging contaminants into the wound; top-to-bottom is standard. Assuming upward cleansing is correct risks infection, critical to prevent in ensuring proper wound hygiene and healing for clients with abdominal incisions during wound care.
Choice D reason: Cleansing drain sites involves circular motion from center outward, not inward, to avoid contamination. Low-pressure irrigation is key for wounds. Assuming inward motion is correct risks infection, critical to avoid in ensuring proper wound and drain care for abdominal incisions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Confirming the client’s perception of the crisis is the first step, establishing trust and understanding their emotional state, critical for effective intervention. This guides tailored support, essential for addressing depression in a situational crisis, ensuring therapeutic communication, and promoting coping in mental health care settings.
Choice B reason: Teaching relaxation techniques is useful but secondary to understanding the client’s crisis perception, which informs interventions. Assuming techniques are first risks misaligned support, potentially escalating distress, critical to avoid in ensuring effective crisis management for clients with depression experiencing situational stressors.
Choice C reason: Identifying strengths supports coping but follows confirming the client’s crisis perception, which sets the therapeutic foundation. Prioritizing strengths risks overlooking the client’s immediate emotional needs, potentially delaying effective intervention, critical to prevent in managing depression during a situational crisis in mental health care.
Choice D reason: Notifying a support person is secondary to understanding the client’s crisis perception, which guides initial intervention. Assuming notification is first risks bypassing the client’s perspective, potentially reducing trust, critical to avoid in ensuring client-centered care for depression in situational crisis management.
Correct Answer is C
Explanation
Choice A reason: Nonlatex gloves are relevant for allergies, not droplet precautions, which require masks. Placing surgical masks is key. Assuming gloves are priority risks neglecting respiratory protection, potentially increasing transmission, critical to avoid in ensuring effective infection control for droplet-borne illnesses in healthcare settings.
Choice B reason: HEPA filtration is for airborne precautions, not droplet, which needs masks. Placing surgical masks is correct. Assuming HEPA is needed risks misapplying resources, potentially diverting focus from droplet transmission prevention, critical to prevent in ensuring proper infection control for clients on droplet precautions.
Choice C reason: Placing surgical masks outside the room is essential for droplet precautions, ensuring staff and visitors wear masks to prevent respiratory transmission. This is critical for infection control, reducing spread, protecting others, and adhering to CDC guidelines for managing droplet-borne infections in healthcare settings.
Choice D reason: Negative pressure rooms are for airborne precautions, not droplet, which requires masks. Assuming negative pressure is needed risks inappropriate room assignment, potentially increasing transmission, critical to avoid in ensuring correct infection control measures for clients on droplet precautions in healthcare facilities.
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