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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use trochanter rolls beside the client's legs.
Trochanter rolls are supportive devices placed alongside the client's hips and thighs to prevent external rotation of the hips and maintain proper alignment of the legs. They help prevent hip abduction and rotation, which can lead to hip dislocation or pressure injuries, especially in immobile clients. Therefore, using trochanter rolls is essential in the care of immobile clients to maintain proper alignment and prevent complications.
B. Place the client's arms at their side when turning them: Placing the client's arms at their side during turning may limit movement and comfort. Instead, the nurse should support the client's arms in a position that promotes comfort and maintains proper alignment.
C. Cross the client's ankles when lying supine: Crossing the client's ankles can lead to compromised circulation and pressure on the bony prominences of the ankles, increasing the risk of pressure injuries. It is not recommended to cross the client's ankles in the supine position.
D. Logroll the client every 4 hr: Logrolling is a technique used to move clients with suspected spinal cord injuries while maintaining spinal alignment. However, it is not necessary to logroll an immobile client every 4 hours unless there are specific indications, such as suspicion of a spinal injury. Frequent repositioning, including the use of trochanter rolls, is essential to prevent pressure injuries and maintain skin integrity but should be individualized based on the client's needs and condition.
Correct Answer is C
Explanation
A. Placing wet towels along the base of the door: While this action may help prevent smoke from entering or exiting the room, it is not the immediate priority. Activating the fire alarm takes precedence to alert others to the fire and initiate the appropriate response.
B. Turning off any electrical equipment: While turning off electrical equipment can reduce the risk of electrical fires, it is not the immediate priority. Activating the fire alarm is the first step to ensure the safety of everyone in the facility.
C. Activate the facility's fire alarm.
Activating the fire alarm is crucial because it immediately alerts others in the facility to the presence of a fire, enabling them to respond appropriately. This action initiates the facility's fire safety protocols, including evacuating the area and summoning professional assistance to extinguish the fire. The sooner the alarm is activated, the quicker the response can be, reducing the risk to individuals and property.
D. Directing a fire extinguisher at the fire: While using a fire extinguisher may be necessary to extinguish the fire, it should only be done after activating the fire alarm to ensure that emergency personnel are alerted and responding to the situation.
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