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 D

Explanation

A. A urine specific gravity of 1.015 is within the normal range (1.005–1.030). While fluid volume excess may lead to a lower specific gravity due to urine dilution, this value does not indicate fluid overload and is considered normal.
B. A hematocrit level of 42% is within the normal range for adults (men: 38–50%, women: 35–45%). Hematocrit levels tend to decrease in fluid volume excess due to hemodilution, but this value does not suggest fluid overload.
C. A urine pH of 6.5 is within the normal range (4.5–8.0). Urine pH reflects the acid-base balance rather than fluid status and is not a reliable indicator of fluid volume excess.
D. A BUN level of 5 mg/dL is below the normal range (10–20 mg/dL). In fluid volume excess, the dilution of blood plasma can lead to decreased BUN levels. This low BUN value, in conjunction with clinical symptoms, supports the diagnosis of fluid volume excess.

A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds. B. Use an adhesive oximetry probe for a client who has a latex allergy. C. Remove polish from the client's fingernail before applying the oximetry probe. D. Lubricate the tip of the oximetry probe.

Correct Answer is C

Explanation

A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.
Capillary refill is assessed to evaluate peripheral perfusion.
B. Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C. Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D. Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.

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