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: A mobile 24 inches above the crib is too high for a 1-week-old’s vision (8-12 inches is ideal), indicating misunderstanding. A ticking clock is soothing. Assuming mobile placement is correct risks reduced stimulation, critical to avoid in supporting infant development and parental education.

Choice B reason: Propping a bottle with a pillow risks choking or aspiration in a 1-week-old; holding is required. A ticking clock is correct. Assuming propping is safe risks infant safety, critical to prevent in ensuring proper feeding practices and parental education for newborns.

Choice C reason: Avoiding frequent holding risks neglecting bonding and comfort needs in a 1-week-old; responsive care is essential. A ticking clock is soothing. Assuming avoidance is correct risks developmental issues, critical to avoid in supporting infant emotional health and parental caregiving education.

Choice D reason: Placing a ticking clock nearby mimics womb sounds, soothing a 1-week-old, promoting sleep and comfort. This understanding is critical for infant well-being, supporting parental caregiving, ensuring a calming environment, and fostering healthy development in the early newborn period at home.

A. Allow your child to swim with supervision. B. Position your child’s casted arm in a sling at bedtime. C. Use a hair dryer on a cool setting to relieve your child’s itching. D. Make sure your child can move their fingers every 6 hours.

Correct Answer is C

Explanation

Choice A reason: Swimming is contraindicated with a fiberglass cast, as water exposure risks skin irritation or cast damage. A hair dryer relieves itching. Allowing swimming risks infection or cast breakdown, critical to avoid in ensuring proper healing and parental education for children with arm casts.

Choice B reason: Positioning the arm in a sling at bedtime is unnecessary; elevation on pillows promotes circulation. A hair dryer addresses itching. Assuming a sling is required risks discomfort, critical to prevent in ensuring proper cast care and comfort for children post-fracture.

Choice C reason: Using a hair dryer on a cool setting safely relieves itching under a fiberglass cast, preventing skin irritation from scratching. This instruction is critical for comfort, ensuring proper cast care, supporting healing, and educating parents on safe management of a child’s arm cast post-injury.

Choice D reason: Checking finger movement every 6 hours is insufficient; frequent checks (e.g., every 2-4 hours) ensure circulation. A hair dryer is correct for itching. Assuming 6-hour checks risks delayed detection of complications, critical to avoid in ensuring safe cast care for children with fractures.

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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?

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Naxlex Comprehensive Predictor Exams

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