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 B

Explanation

A. "I will move your joints to the point of mild pain." - This statement is incorrect. Passive ROM exercises should not be performed to the point of causing pain. Pain during passive ROM exercises can indicate that the movement is too forceful or beyond the client's range of motion, which can lead to injury or discomfort.

B. "I will repeat these movements 3 to 5 times." - This statement is generally correct. Passive ROM exercises are typically repeated several times during each session to help maintain joint mobility and prevent contractures. The specific number of repetitions can vary based on the client's needs and tolerance.

C. "I will move your joints quickly." - This statement is incorrect. Passive ROM exercises should be performed slowly and gently to avoid causing discomfort or injury to the client. Slow movements allow for better control and precision, ensuring that the joints are moved through their full range of motion without undue force.

D. "These movements will be performed once per day." - This statement is incorrect. Passive ROM exercises are usually performed multiple times throughout the day, especially for clients with decreased mobility. Regular and frequent sessions help prevent stiffness, maintain flexibility, and promote circulation in the joints.

A. "I will walk three times per week." B. "I will avoid exposure to the sun." C. "I will decrease my intake of dairy products." D. "I will take 250 milligrams of calcium once per day."

Correct Answer is A

Explanation

A. "I will walk three times per week."

Regular weight-bearing exercises, such as walking, are beneficial for maintaining bone density and reducing the risk of osteoporosis in older adults. Weight-bearing activities help stimulate bone formation and strengthen bones. Therefore, the client's statement about walking three times per week demonstrates an understanding of an effective measure for reducing the risk of osteoporosis.

B. "I will avoid exposure to the sun." - Exposure to sunlight is essential for vitamin D synthesis, which helps the body absorb calcium and maintain bone health. Therefore, avoiding sunlight would not be beneficial for reducing the risk of osteoporosis.

C. "I will decrease my intake of dairy products." - Dairy products are a rich source of calcium, which is crucial for bone health. Decreasing intake of dairy products may lead to inadequate calcium intake, increasing the risk of osteoporosis.

D. "I will take 250 milligrams of calcium once per day." - While calcium supplementation is important for maintaining bone health, the recommended daily intake for older adults is higher than 250 milligrams. The client's statement suggests an inadequate understanding of calcium supplementation for osteoporosis prevention.

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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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