A nursing home client exhibits the following symptoms: boredom, restlessness, and depression. Based on this data, the nurse identifies a potential problem of:

A. "The drainage tube is used to prevent infection at the site of the surgical repair.": Hemovac drains are designed to remove excess blood, serous fluid, and exudate from the surgical site. By continuously evacuating fluid, the drain decreases the risk of fluid accumulation, which can serve as a medium for bacterial growth, thereby reducing the likelihood of postoperative infection and promoting proper wound healing.

B. "The drainage tube is used to prevent bleeding at the site of the surgical repair.": While the drain collects blood that has already leaked, it does not actively prevent bleeding. Hemostasis during surgery and postoperative monitoring are the main methods for controlling bleeding, not the presence of a drain.

C. "The drainage tube is used to prevent pressure on the bladder.": A Hemovac drain is not connected to the urinary system and does not relieve bladder pressure. Its purpose is strictly related to fluid removal from the surgical site, not urinary management.

D. "The drainage tube is used in case the wound needs irrigated.": Although some wounds may be irrigated through a drain if prescribed, the primary purpose of a Hemovac drain is to evacuate fluid and reduce infection risk. It is not routinely used as an access point for irrigation.

A. Dispose used gauze and supplies in appropriate receptacle: While proper disposal of contaminated supplies is important for infection control, it does not demonstrate understanding of the sterile wound irrigation technique itself. This action is part of standard post-procedure cleanup rather than the key procedural step.

B. Apply prescribed sterile dressing to wound bed if packing is prescribed: Applying a sterile dressing is part of wound care management, but it occurs after irrigation and does not directly reflect the nurse’s technique or knowledge in performing the irrigation correctly.

C. Stop the irrigation once the wound solution flows clear: Correct sterile wound irrigation involves continuing the process until the irrigating solution is free of debris and exudate, ensuring that contaminants, necrotic tissue, or drainage are effectively removed. This demonstrates proper technique and promotes optimal wound healing while maintaining sterility.

D. Perform hand hygiene after removing all PPE: Performing hand hygiene is a standard infection control measure, essential for safety but unrelated to demonstrating competence in the sterile irrigation technique. It is a general practice rather than a key indicator of correct procedural performance.