A nurse is observing a new nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the new nurse understands wound irrigation?

Cleanses the wound with povidone-iodine on cotton balls

Administers analgesia PO 20 min prior to irrigation

Warms the irrigation solution in the microwave prior to application

Irrigates the wound from the cleanest to the most contaminated area

Answer and Explanation

The Correct Answer is D

Choice A reason: Cleansing wounds with povidone-iodine on cotton balls is not recommended because it can damage granulation tissue and delay healing. Cotton fibers may also remain in the wound, increasing infection risk.

Choice B reason: Administering analgesia prior to irrigation is appropriate for pain management but does not directly demonstrate correct irrigation technique. While important, it is not the best indicator of proper wound irrigation practice.

Choice C reason: Warming irrigation solution in the microwave is unsafe because it can cause uneven heating and burns. Solutions should be warmed to room temperature using safe methods, not microwaves.

Choice D reason: Irrigating from the cleanest to the most contaminated area is the correct technique. This prevents the spread of microorganisms from contaminated areas into clean tissue, promoting healing and reducing infection risk.

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Correct Answer is D

Explanation

Choice A reason: Older adults have an increased risk, not decreased risk, for atelectasis due to reduced lung elasticity, weaker respiratory muscles, and decreased cough reflex.

Choice B reason: Diaphragmatic movement decreases with age because of muscle weakening and changes in thoracic structure. Increased diaphragmatic movement is not an age-related change.

Choice C reason: Chest wall compliance decreases with age due to calcification of costal cartilage and stiffening of the thoracic cage. Increased compliance is incorrect.

Choice D reason: Decreased blood oxygenation is correct. Aging reduces alveolar surface area and capillary perfusion, leading to lower arterial oxygen levels. This physiologic change must be considered when planning activities to avoid hypoxemia and fatigue.

A. Place the client in a prone position. B. Insert a padded tongue blade into the client's mouth. C. Loosen the client's restrictive clothing. D. Restrict the movement of the client's extremities.

Correct Answer is C

Explanation

Choice A reason: Placing the client in a prone position is unsafe during a seizure. The prone position can obstruct the airway and increase the risk of aspiration. The client should be placed on their side to maintain airway patency.

Choice B reason: Inserting any object, including a padded tongue blade, into the client’s mouth during a seizure is contraindicated. This can cause oral trauma, broken teeth, or airway obstruction.

Choice C reason: Loosening restrictive clothing helps prevent injury and promotes adequate ventilation during a seizure. It reduces the risk of airway compromise and allows the client to move freely without restriction. This is the correct intervention.

Choice D reason: Restricting extremity movement during a seizure can cause musculoskeletal injury. The nurse should allow the seizure to occur naturally while ensuring the environment is safe and the client is protected from harm.

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A nurse is observing a new nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the new nurse understands wound irrigation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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