After closing the curtain around the client’s bed and lifting his gown to expose the horizontal abdominal wound, which of the following positions should you assist the client into for comfortable wound irrigation?
High-Fowler’s
Side-lying
Supine
Dorsal Recumbent
The Correct Answer is A
Choice A rationale
The High-Fowler’s position, with the client sitting upright at a 90-degree angle, is ideal for abdominal wound irrigation as it reduces the risk of fluid accumulation in the wound area and promotes drainage.
Choice B rationale
The side-lying position is not typically used for abdominal wound irrigation because it can cause pooling of the irrigation solution and does not facilitate easy access to the wound site.
Choice C rationale
The supine position, with the client lying flat on their back, is not suitable for abdominal wound irrigation as it can lead to fluid retention in the wound and does not aid in drainage.
Choice D rationale
The dorsal recumbent position, with the client lying on their back with knees bent, is also not optimal for abdominal wound irrigation due to the potential for fluid to collect in the wound area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While an abdominal binder may be helpful postoperatively, it is not the immediate intervention for a patient who feels that ‘something just let go’ after surgery.
Choice B rationale
Seating the patient in a nearby chair is not the best initial action as it may increase abdominal pressure and potentially worsen any underlying issue.
Choice C rationale
Instructing the patient to pant is not an appropriate response to a potential complication from surgery, such as dehiscence or evisceration.
Choice D rationale
The best initial action is to assist the patient into a supine position to minimize tension on the abdominal incision, reduce the risk of further injury, and assess the situation.
Correct Answer is D
Explanation
Choice A rationale
An abrasion occurs when the skin is scraped off, usually due to a surface rubbing or scraping against the skin. It does not involve pooling of blood under the skin but rather an injury to the top layer of the skin.
Choice B rationale
An avulsion is a severe type of wound that occurs when a portion of the skin and sometimes the tissue beneath is partially or completely torn away. It is not characterized by pooling of blood under unbroken skin.
Choice C rationale
A laceration refers to a deep cut or tear in the skin or flesh. Because lacerations imply that the skin is broken and torn, it does not describe the condition where blood pools under unbroken skin.
Choice D rationale
A hematoma is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This is the correct term for a pooling of blood under unbroken skin, as described in the scenario following the patient’s fall. Hematomas can be caused by injury, such as a fall, that causes blood vessels to break and bleed into the surrounding tissues.
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