A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?

Administer an analgesic 30 min before starting the procedure.

Hold the syringe 5 cm (2 in) above the upper end of the wound.

Place the irrigation solution in a basin of cool water.

Perform the wound irrigation with a 10mL syringe with an angiocatheter.

Answer and Explanation

The Correct Answer is A

A.   Administer an analgesic 30 min before starting the procedure: Correct. Before performing wound irrigation, it is essential to provide pain relief to the client. Administering an analgesic 30 minutes before the procedure will help manage pain during wound irrigation.
B.   Hold the syringe 5 cm (2 in) above the upper end of the wound: This action does not contribute to proper wound irrigation. The nurse should direct the irrigation solution to the wound site to cleanse it effectively.
C.   Place the irrigation solution in a basin of cool water: Using cool water is not the best practice for wound irrigation. The irrigation solution should be at room temperature or a temperature specified by the healthcare provider.
D.   Perform the wound irrigation with a 10mL syringe with an angiocatheter: Wound irrigation typically requires a larger volume of fluid to adequately cleanse the wound. A 10mL syringe may not be sufficient, and using an angiocatheter is not appropriate for wound irrigation. A larger syringe or irrigation solution bag with an appropriate wound irrigation tool is usually used.

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Correct Answer is C

Explanation

A: While explaining the negative consequences of refusal is important, it may not change the client's decision, and respect for the client's autonomy must be upheld.
B: Discussing the treatment with the client's partner without the client's consent may breach patient confidentiality and privacy.
C: Correct. The nurse should document the client's refusal of the medical treatment in the client's medical record. This documentation is essential for legal and ethical purposes and to ensure that the refusal is adequately communicated to the healthcare team.
D: Trying to convince the client to undergo the treatment is not appropriate and may violate the principle of informed consent. The client has the right to refuse treatment after being adequately informed of the risks and benefits.

A. Apply thromboembolic stockings. B. Monitor the circulation in all four extremities. C. Record the condition of the client's skin.

Correct Answer is A

Explanation

A: Correct. Applying thromboembolic stockings (compression stockings) to the client's legs is a task that can be safely delegated to assistive personnel. The nurse should provide clear instructions on how to apply them properly.
B: Incorrect. Monitoring the circulation in all four extremities requires clinical judgment and skilled assessment, and it should not be delegated to assistive personnel.
C: Incorrect. Recording the condition of the client's skin requires observation and assessment, which should not be delegated to assistive personnel.

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Nursing Test Bank

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