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 B
Explanation
Choice A rationale:
An alert and responsive client who eats 25% of each meal may have nutritional deficiencies, but is able to change position to relieve pressure.
Choice B rationale:
A client who is unresponsive to verbal commands and only changes position occasionally is at high risk for pressure injury due to prolonged pressure on certain areas of the body.
Choice C rationale:
A client who makes frequent slight changes in position and walks occasionally is not at high risk for pressure injury.
Choice D rationale:
A client receiving enteral feeding and can change position independently is not at high risk for pressure injury.
Correct Answer is A
Explanation
Choice A rationale:
Testing the temperature of the solution is crucial to prevent burns.
Choice B rationale:
While using sterile equipment and solution is important, it’s not the most important in a hot soak treatment.
Choice C rationale:
Comfort is important but not as critical as preventing burns.
Choice D rationale:
Soaking only the affected area is good practice but not as vital as preventing burns.
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