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. Full thickness skin loss with visible bone:
This describes a stage 4 pressure injury.
B. Full thickness skin loss with visible adipose tissue:
This describes a stage 3 pressure injury.
C. Partial-thickness skin loss with red tissue in wound bed:
Stage 2 pressure injuries involve partial-thickness skin loss, sometimes with a pink or red wound bed and may include blistering.
D. Intact skin with localized erythema:
This describes a stage 1 pressure injury.
Correct Answer is B
Explanation
A. "Fortunately, hypertension isn’t related to other diseases and is easily treated":
This is misleading-hypertension is related to many other diseases (e.g., cardiovascular, renal).
B. "A single reading may not mean anything. We will take it again, 2 more times, within the next few weeks.":
Hypertension diagnosis requires two or more elevated readings on separate occasions. One elevated BP does not confirm diagnosis.
C. "It looks like you have high blood pressure now. We'll check it again in 3 months":
Waiting 3 months may delay early detection. BP should be rechecked within a few weeks to confirm or rule out hypertension.
D. "You may have hypertension, but there is little else that can be done except medication":
Hypertension can often be managed with lifestyle changes in addition to or instead of medication, especially initially.
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