A nurse is preparing to assist with irrigating a wound for a client. Which of the following actions should the nurse plan to take?
Irrigate the wound until the solution that is draining is clear.
Hold the tip of the syringe inside of the wound while irrigating.
Flush the wound from the most contaminated area to the cleanest area.
Chill the irrigant prior to the procedure.
The Correct Answer is A
A. Irrigate the wound until the solution that is draining is clear:
Continue irrigation until visible debris and drainage are removed, and the fluid runs clear, indicating cleanliness.
B. Hold the tip of the syringe inside of the wound while irrigating:
This can cause tissue trauma. The syringe should be held just above the wound.
C. Flush the wound from the most contaminated area to the cleanest area:
Always cleanse from the cleanest to the most contaminated area to prevent spread of microorganisms.
D. Chill the irrigant prior to the procedure:
Room temperature or warmed solutions are preferred to prevent lowering the tissue temperature, which can delay healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Massage reddened areas during dressing changes:
Massaging reddened or compromised skin can worsen tissue damage and increase the risk of further injury.
B. Apply a heat lamp twice a day:
Heat lamps are not recommended and may dry out the wound bed or burn healing tissue.
C. Cleanse with 0.9% sodium chloride irrigation:
Normal saline is gentle and effective for cleaning granulating tissue without causing damage or cytotoxic effects.
D. Cleanse with povidone-iodine solution:
Povidone-iodine is cytotoxic and can impair wound healing, especially to new granulating tissue.
Correct Answer is B
Explanation
A. Adequate hydration:
Adequate hydration helps maintain skin integrity and reduces the risk of pressure injury.
B. Chronic diseases:
Conditions like diabetes, vascular disease, and immobility compromise tissue perfusion and healing, increasing pressure injury risk.
C. Elevated blood pressure:
Elevated BP alone doesn't directly increase risk for pressure injuries; poor perfusion (as in low BP) is a greater risk.
D. Regular exercise routine:
Exercise promotes circulation and mobility, decreasing the risk of pressure injuries.
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