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

Cleanses the wound with povidone-iodine on cotton balls

Administers PO analgesia 20 min prior to irrigation

Warms the irrigation solution in the microwave oven prior to application

Irrigates the wound from the top to the bottom

Answer and Explanation

The Correct Answer is D

A. Povidone-iodine may be used as a wound cleanser, but the method described here (using cotton balls) is not typically recommended as it can leave fibers in the wound.

B. Administering oral analgesia prior to wound irrigation may be appropriate for pain management but is not directly related to understanding wound irrigation technique.

C. Warming irrigation solution in a microwave oven can lead to uneven heating and potential tissue damage. This method is not recommended for warming irrigation solution.

D. Irrigating the wound from the top to the bottom ensures that contaminants are flushed away from the wound site, reducing the risk of infection and promoting healing. This indicates an understanding of proper wound irrigation technique.

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Correct Answer is C

Explanation

A. Dependent edema is a sign of fluid overload or right-sided heart failure but is not immediately life-threatening.
B. A pericardial friction rub is a characteristic finding of pericarditis but does not indicate imminent compromise.
C. A paradoxical pulse (pulsus paradoxus) can indicate cardiac tamponade, a life-threatening complication of pericarditis. Prompt recognition and intervention are critical.
D. Substernal chest pain is a common symptom of pericarditis and should be addressed, but it is not as immediately dangerous as signs of cardiac tamponade.

A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis. B. Hepatitis B is transmitted by contaminated food. C. Chronic hepatitis can lead to renal cell cancer. D. Clients who have a history of viral hepatitis are unable to donate blood.

Correct Answer is D

Explanation

- Choice A: The recommended hepatitis vaccine series is not a series of four. The Advisory Committee on Immunization Practices (ACIP) recommends a three-dose series for hepatitis B vaccination.
- Choice B: Hepatitis B is not typically transmitted by contaminated food. It is primarily spread through direct contact with infectious blood, semen, or other body fluids.
- Choice C: While there is some evidence suggesting a link between chronic hepatitis C infection and an increased risk of renal cell carcinoma, the statement is not universally accepted as fact and more research is needed to establish a definitive connection.
- Choice D: Individuals with a history of hepatitis B or C are generally ineligible to donate blood due to the risk of transmission of these bloodborne viruses.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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