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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Art therapist: Art therapy can provide a nonverbal outlet for expressing feelings and emotions, which can be particularly beneficial for clients with schizophrenia who may struggle with verbal communication.
B. Speech-language pathologist: While speech-language pathologists may assist with communication difficulties, their expertise is more focused on speech and language disorders rather than addressing emotional expression in clients with schizophrenia.
C. Social worker: Social workers provide support and assistance with various psychosocial
issues, but they may not specifically address the client's difficulty expressing feelings through therapeutic interventions like art therapy.
D. Recreational therapist: Recreational therapy focuses on promoting leisure and recreational
activities to improve overall well-being, but it may not directly address the client's difficulty with emotional expression.
Correct Answer is C
Explanation
A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.
B. Notifying the client's provider may be necessary, but it is not the immediate priority.
C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.
D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.
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