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:
Third intention healing, also known as delayed primary closure, is used when wound closure is delayed due to infection risk.
Choice B rationale:
First intention healing occurs when the wound edges are approximated, such as with sutures.
Choice C rationale:
Second intention healing occurs when the wound edges cannot be approximated and the wound heals from the bottom up.
Choice D rationale:
Fourth intention healing is not a recognized term in wound healing.
Correct Answer is B
Explanation
Choice A rationale:
Decreased serum calcium does not directly contribute to pressure injury development.
Choice B rationale:
Decreased circulation can lead to tissue ischemia and necrosis, increasing the risk of pressure injury.
Choice C rationale:
Increased collagen is beneficial for wound healing and does not increase the risk of pressure injury.
Choice D rationale:
Increased muscle mass can actually provide more padding over bony prominences, reducing the risk of pressure injury.
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