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. Metabolic syndrome: Metabolic syndrome is a cluster of conditions that occur together, increasing the risk of cardiovascular disease, stroke, and type 2 diabetes. The conditions include increased blood pressure, high blood sugar levels, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Metabolic syndrome significantly increases the risk of developing cardiovascular disease by promoting atherosclerosis (hardening and narrowing of the arteries) and increasing the likelihood of developing other risk factors such as hypertension and diabetes.
B. Family history of alcohol use disorder: While excessive alcohol consumption can contribute to cardiovascular disease by raising blood pressure, increasing triglyceride levels, and promoting obesity, a family history of alcohol use disorder alone is not considered a direct risk factor for cardiovascular disease.
C. Participation in competitive sports: Regular physical activity, including participation in competitive sports, is typically associated with a reduced risk of cardiovascular disease. However, extreme levels of physical activity or certain types of competitive sports may pose risks, such as sudden cardiac events in individuals with underlying heart conditions. Overall, regular exercise is beneficial for cardiovascular health when performed in moderation and according to individual fitness levels.
D. Hypotension: Hypotension, or low blood pressure, is generally not considered a significant risk factor for cardiovascular disease. In fact, low blood pressure is often associated with a reduced risk of conditions such as heart attack and stroke. However, severe hypotension can indicate underlying health issues and may require medical evaluation and management.
Correct Answer is D
Explanation
A. A feeling of swelling in the feet: Swelling in the feet can be caused by various factors such as fluid retention, circulatory issues, or certain medical conditions like venous insufficiency. It is not a typical symptom of anaphylaxis, which usually involves more generalized symptoms such as hives, itching, swelling of the face or throat, difficulty breathing, and a drop in blood pressure.
B. Pain at the injection site: Pain at the injection site is a common side effect of receiving an injection or medication. It occurs due to tissue irritation or trauma from the needle. While allergic reactions can cause localized redness, swelling, or itching at the injection site, severe pain alone is not a hallmark symptom of anaphylaxis.
C. A sudden decrease in heart rate: Anaphylaxis typically leads to an increase in heart rate (tachycardia) rather than a decrease. This increase in heart rate is a response to the body's attempt to compensate for the drop in blood pressure caused by anaphylaxis. Bradycardia (a decrease in heart rate) is not a typical feature of anaphylaxis unless it occurs very late in a severe reaction due to profound circulatory collapse.
D. A sharp decrease in blood pressure: This choice is indicative of an understanding of possible anaphylaxis. Anaphylaxis can cause a rapid and severe drop in blood pressure, known as hypotension. This drop in blood pressure is often a key feature of anaphylaxis and can lead to symptoms such as dizziness, fainting, confusion, and shock.

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