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.
Chill the irrigant prior to the procedure.
Hold the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating.
Flush the wound from the most contaminated area to the cleanest area.
The Correct Answer is A
Choice A rationale:
The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.
Choice B rationale:
The irrigant should be at room temperature, not chilled.
Choice C rationale:
The syringe should be held 1 inch (not 0.5 inch) from the wound.
Choice D rationale:
The wound should be flushed from the cleanest area to the most contaminated, not the other way around.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Massaging bony prominences can lead to tissue ischemia and damage, increasing the risk of pressure injuries.
Choice B rationale:
Repositioning should be done every 2 hours or less for at-risk patients.
Choice C rationale:
Elevating the head of the bed more than 30° can increase shear and friction, leading to pressure injuries.
Choice D rationale:
A high-calorie diet can promote skin integrity and wound healing.
Correct Answer is C
Explanation
Choice A rationale:
While it’s important for the patient to remain still during the procedure, this is not the most important aspect of changing a sterile dressing.
Choice B rationale:
Placing a discard bag close to the wound can increase the risk of infection.
Choice C rationale:
Changing gloves after removing the old dressing is crucial to maintain sterility and prevent infection.
Choice D rationale:
Refraining from talking while the wound is uncovered can help prevent infection, but it’s not as important as changing gloves after removing the old dressing.
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