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 A
Explanation
Choice A rationale
A Stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area, usually over a bony prominence. The presence of pain and redness that does not blanch when pressure is applied are indicative of this early stage of pressure injury.
Choice B rationale
Stage 2 pressure injuries involve partial-thickness loss of dermis and present as a shallow open ulcer with a red-pink wound bed, without slough. This does not match the description of the patient’s condition, which indicates intact skin.
Choice C rationale
Stage 3 pressure injuries are defined by full-thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. The patient’s symptoms do not suggest such an advanced stage.
Choice D rationale
Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Since the patient’s skin is intact and only red, this stage does not apply.
Correct Answer is B
Explanation
Choice A rationale
A contusion, commonly known as a bruise, is characterized by bleeding under the skin, causing discoloration and swelling. It does not involve a break in the skin and therefore does not match the description of the wound with torn skin tissue.
Choice B rationale
A laceration refers to a deep cut or tear in the skin or flesh. Because the nurse discovered torn skin tissue, this type of wound is consistent with the client’s injury described in the scenario.
Choice C rationale
An abrasion is a wound caused by superficial damage to the skin, usually no deeper than the epidermis. It is typically caused by a scrape against a rough surface and is not associated with torn skin tissue.
Choice D rationale
A puncture is a small hole caused by a long, pointed object, such as a nail or needle. This type of wound usually does not result in torn skin tissue but rather a deeper, more narrow penetration.
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