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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The hypoglossal nerve is tested by checking for tongue deviation.

B. This action tests the facial nerve

C. This action tests the trigeminal nerve

D. This action tests the spinal accessory nerve

A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin. B. Unlock and remove the inner cannula. C. Scrub the inside and outside of the inner cannula with a small brush. D. Wipe the inside of the inner cannula with a folded pipe cleaner. E. Cleanse the stoma site with 0.9% sodium chloride solution.

Correct Answer is A,B,C,D,E

Explanation

Pouring 0.9% sodium chloride solution into the sterile basin provides the solution necessary for cleaning the inner cannula.

Unlocking and removing the inner cannula is the first step in the process of tracheostomy care.

Scrubbing the inside and outside of the inner cannula with a small brush helps remove secretions and debris.

Wiping the inside of the inner cannula with a folded pipe cleaner further cleans the inner surfaces.

Cleansing the stoma site with 0.9% sodium chloride solution completes the tracheostomy care procedure.

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A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data about cranial nerve function from an adult client. Which of the following images depicts the method the nurse should use to check the function of the hypoglossal cranial nerve (XII)? Image A B. C. Image B Image C Image D

Correct Answer is A

Explanation

48. A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,D,E

Explanation

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