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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Alone time for reflection may increase rumination in alcohol use disorder, not fostering self-control; positive feedback reinforces coping. Assuming alone time helps risks isolation, potentially worsening stress, critical to avoid in supporting adaptive behaviors and recovery in clients with alcohol use disorders.

Choice B reason: Gradual alcohol reduction is not ideal for alcohol use disorder, where abstinence is often recommended; positive feedback supports coping. Assuming reduction is effective risks enabling continued use, delaying recovery, critical to prevent in fostering self-control and sobriety in clients with alcohol dependence.

Choice C reason: Having the partner monitor alcohol intake undermines client autonomy, not promoting self-control; positive feedback reinforces independence. Assuming partner responsibility risks dependency, potentially hindering personal accountability, critical to avoid in supporting self-managed recovery in clients with alcohol use disorder.

Choice D reason: Giving positive feedback for adaptive coping strategies reinforces healthy stress management, promoting self-control in alcohol use disorder. This builds confidence, critical for sustained sobriety, encouraging alternative coping mechanisms, and supporting long-term recovery, essential for effective behavioral change in clients managing stress without alcohol.

A. Persistent headache. B. Weight gain 2.3 kg (5 lb). C. Frequent nausea. D. Breast tenderness.

Correct Answer is A

Explanation

Choice A reason: Persistent headache on oral contraceptives may indicate serious complications like stroke or hypertension, requiring immediate reporting to prevent life-threatening events. This is critical for timely intervention, ensuring client safety, and guiding potential medication adjustments in women using hormonal contraception for 6 months.

Choice B reason: Weight gain of 2.3 kg is common with oral contraceptives and not urgent, unlike persistent headache, which signals serious risks. Assuming weight gain requires reporting risks overlooking critical neurological symptoms, critical to avoid in ensuring safe monitoring of contraceptive side effects.

Choice C reason: Frequent nausea is a common contraceptive side effect, typically managed with counseling, not urgent like headache. Assuming nausea is priority risks delaying serious symptom evaluation, critical to prevent in ensuring timely reporting of potentially life-threatening complications in contraceptive users.

Choice D reason: Breast tenderness is a common, non-urgent side effect of oral contraceptives, unlike persistent headache, which may indicate stroke risk. Assuming tenderness is urgent risks missing critical symptoms, critical to avoid in ensuring proper monitoring and safety in clients on hormonal contraception.

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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

Naxlex Comprehensive Predictor Exams

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