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 A
Explanation
A. A falsely high reading if the cuff is too small:
Using a cuff that is too narrow for the arm circumference can compress the artery more, resulting in a false high BP.
B. A falsely low reading if the cuff is wrapped too loosely around the arm:
This is true if a cuff is loose, but the question focuses on using a standard-size cuff, not an improperly applied one.
C. Accurate readings as long as it is 20% of the circumference of the midpoint of the limb:
The correct cuff width should be 40% of the limb’s circumference, and the bladder length should cover 80% of the arm.
D. Indistinct readings if the bladder encircles 80% of the adult's arm:
A bladder covering 80% of the arm is ideal and yields accurate readings.
Correct Answer is B
Explanation
A. Hydrofiber dressing:
Hydrofiber dressings are designed for moderate to heavy exudate, not dry or non-exudative wounds.
B. Transparent-film dressing:
Transparent-film dressings are ideal for superficial, non-draining wounds like skin tears. They protect the area while allowing for oxygen exchange and visualization of the wound.
C. Alginate dressing:
Alginate dressings are highly absorbent and used for moderate to heavy exudating wounds, not for dry superficial tears.
D. Foam dressing:
Foam dressings are best for wounds with exudate. They are thicker and may not adhere well to superficial skin tears without drainage.
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