A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
Use a 10-mL syringe filled with cleansing solution.
Dry the wound bed with gauze squares.
Cleanse the wound with cotton balls.
Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
The Correct Answer is A
A. Using a 10-mL syringe filled with cleansing solution provides appropriate pressure for effective wound irrigation.
B. Drying the wound bed with gauze squares is not typically recommended as it may disrupt healing and cause trauma to the wound.
C. Cleansing the wound with cotton balls may leave fibers behind and is not the most effective method of wound irrigation.
D. Holding the syringe tip 2.5 cm (1 in) above the wound is incorrect; the tip should be inserted into the wound to facilitate thorough irrigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Completing an incident report about the breach of confidentiality may be necessary, but it
should not be the first action. The immediate concern is addressing the behavior and reminding the nurse of proper protocol.
B. While it may be true that permission from the risk manager is required to access certain
records, this response does not address the immediate issue of the unauthorized access. It's more important to address the behavior directly.
C. This is the most appropriate action because it directly addresses the unauthorized access to the client's medical record. Reminding the nurse of the proper protocol for accessing medical records can help prevent further breaches of confidentiality.
D. Contacting facility security to remove the nurse from the unit may be excessive at this stage and should be considered if the behavior persists after reminders about proper protocol.
Correct Answer is C
Explanation
A. Documenting client education on self-care needs is important but does not specifically relate to the postpartum status or immediate healthcare concerns.
B. While documenting vital signs like oral temperature is important for monitoring the client's health, this specific finding does not relate directly to the postpartum status unless it is elevated beyond normal ranges and indicates a potential complication.
C. Documenting the condition of the episiotomy site, including its approximation and length, is essential for assessing wound healing and preventing infection in the postpartum period.
D. While hydration is important for postpartum recovery, documenting fluid intake is not as crucial as assessing the healing of specific postpartum interventions like an episiotomy.
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