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. Ask the client to cough every 4 hr:
Coughing can help clear secretions, but doing so only every 4 hours is not sufficient for hypoxia. More immediate action is needed.
B. Decrease the head of the client’s bed:
Lowering the head of the bed reduces lung expansion and worsens oxygenation.
C. Encourage the client to take deep breaths:
Deep breathing improves alveolar expansion and oxygen exchange, which helps raise oxygen saturation.
D. Request a prescription for an opioid analgesic:
Opioids can depress respiratory drive, further lowering oxygen levels unless pain is clearly affecting breathing.
Correct Answer is B
Explanation
A. Use a cotton-tipped applicator to remove cerumen:
Inserting objects like cotton-tipped swabs into the ear canal is unsafe and can cause damage; not recommended for clearing earwax before temperature measurement.
B. Insert the probe snugly into the ear canal and press scan:
This is the correct method to ensure an accurate tympanic temperature reading.
C. Pull the pinna downward and backward:
This is correct for children under 3 years, not for adults.
D. Hold the probe flat against the forehead and press scan:
This technique is for a temporal artery thermometer, not tympanic.
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