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","C","D","E"]
Explanation
E.
Choice A rationale:
A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of a pressure injury.
Choice B rationale:
Peripheral neuropathy can lead to a loss of sensation, which increases the risk of a pressure injury as the individual may not feel discomfort or recognize the need to reposition.
Choice C rationale:
Immobility is a major risk factor for pressure injuries as it increases pressure on certain areas of the body, reducing blood flow and leading to tissue damage.
Choice D rationale:
Hypoperfusion, or reduced blood flow, can lead to tissue hypoxia and increase the risk of pressure injuries.
Choice E rationale:
A prealbumin level of 16 mg/dL is at the lower end of the normal range (15-36 mg/dL)2. Low prealbumin levels can indicate poor nutritional status, which is a risk factor for pressure injuries.
Correct Answer is A
Explanation
Choice A rationale:
Alginate dressings are highly absorbent and suitable for wounds with heavy drainage. They also promote hemostasis by activating the intrinsic pathway of the clotting cascade.
Choice B rationale:
Dry gauze is not the best choice for a bleeding wound as it does not have hemostatic properties.
Choice C rationale:
Hydrogel dressings are primarily for wounds with little to no exudate and not suitable for a bleeding wound.
Choice D rationale:
Transparent dressings are thin, waterproof dressings used for superficial wounds and not suitable for a bleeding wound.
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