A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?

Uses one pair of gloves for dressing removal and irrigation

Uses a syringe with a catheter for wound irrigation

Administers an analgesic medication 5 min before starting irrigation

Refrigerates the solution before irrigation

Answer and Explanation

The Correct Answer is B

A. Uses one pair of gloves for dressing removal and irrigation:

It is essential to change gloves between different steps of wound care to prevent cross-contamination and infection. Using the same pair of gloves for dressing removal and irrigation increases the risk of introducing pathogens into the wound, which can lead to infection.

B. Uses a syringe with a catheter for wound irrigation.

Using a syringe with a catheter for wound irrigation allows for controlled and precise delivery of the irrigation solution to the wound site. It helps ensure that the wound is thoroughly cleansed without causing excessive pressure or trauma to the surrounding tissue.

C. Administers an analgesic medication 5 minutes before starting irrigation:

While administering analgesic medication may help alleviate the client's pain during wound irrigation, it is not directly related to the procedural aspect of wound irrigation. Pain management is an essential component of wound care, but it does not demonstrate an understanding of the specific procedure of wound irrigation.

D. Refrigerates the solution before irrigation:

Refrigerating the irrigation solution is not necessary and may cause discomfort to the client when cold solution is used for wound irrigation. Wound irrigation solutions are typically used at room temperature to avoid temperature-related discomfort and to maintain the integrity of the solution.

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Correct Answer is A

Explanation

A. Asking the family if they wish to assist in washing the client's body:

This is an important first step because it respects the family's cultural or religious practices and allows them to participate in the care of their loved one if they choose. It sets the tone for sensitive and respectful postmortem care.

B. Removing the client's dentures for their family to keep:

Dentures are usually leftin the mouth tomaintain facial shape.However, this action is not the first priority.

C. Leaving the client's eyes open until the family views the body:

It is generally recommended to gently close the client's eyes after death as part of the postmortem care process. Leaving the eyes open might be distressing for the family, so this action should not be performed first.

D. Turn overhead lights to a bright setting.

Bright lighting may not be comforting for the family or create a peaceful environment. Dim or soft lighting is usually preferred to create a calming atmosphere during this sensitive time. Therefore, this is not the first action the nurse should take.

A. Combine the medications with the formula in the feeding bag. B. Dilute each crushed medication with warm water. C. Flush the NG tube with 5 mL of sterile water for irrigation prior to administration. D. Mix the medications together in a single syringe

Correct Answer is C

Explanation

. Combine the medications with the formula in the feeding bag:

Combining medications with the enteral feeding formula in the feeding bag is not recommended as it may alter the medication's efficacy or stability. Additionally, mixing medications with the feeding formula could result in interactions between the medications or between the medications and the formula components.

B. Dilute each crushed medication with warm water:

While diluting crushed medications with warm water may facilitate administration through the NG tube, it is not always necessary or appropriate for all medications. Dilution should be done according to specific medication guidelines or manufacturer recommendations. Some medications may not require dilution, while others may require a specific diluent or method of administration.

C. Flush the NG tube with 5 mL of sterile water for irrigation prior to administration.

Flushing the NG tube with 30-60ml sterile water for irrigation before administering medications helps ensure that the tube is clear of any residual feeding formula or medication residue. This step helps prevent potential clogging of the tube and ensures that the medications are delivered effectively to the client's stomach or intestines.

D. Mix the medications together in a single syringe:

Mixing medications together in a single syringe may increase the risk of drug interactions or chemical incompatibilities between the medications. Each medication should be administered separately to ensure accurate dosing and prevent potential interactions. Administering medications separately also allows for better monitoring of the client's response to each medication.

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A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?

Nursing Test Bank

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Explanation

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Correct Answer is C

Explanation

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