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 A
Explanation
A. This response acknowledges the client's concerns and opens the conversation for the nurse to address the client's specific needs and preferences, which is crucial in end-of-life care.
B. While pain management is important, addressing the client's concerns about the end-of-life care and their expectations should be the priority.
C. While family visits are significant, addressing the client's immediate concerns about their care takes precedence.
D. Spiritual support is important but may not address the client's immediate concerns about the care they will receive as death approaches.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
At 1000, when the nurse enters the client's room and the client is experiencing an aura followed by generalized jerking contractions of arms and legs, the first action the nurse should take is to ensure the client's safety. This includes removing any potential hazards from the immediate vicinity, such as pillows that could obstruct the airway or cause suffocation.
The next critical action is to turn the client to their side, which helps maintain an open airway, allows for any secretions to drain, and reduces the risk of aspiration should vomiting occur. These steps are vital in managing a seizure and are part of the standard care procedures to protect the client during and after a seizure episode.
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