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. Chvostek's sign is a clinical sign observed during physical examination that may indicate hypocalcemia. It is elicited by tapping or lightly striking the facial nerve just anterior to
the earlobe, which can cause twitching of the facial muscles, particularly the muscles around the mouth and nose.
B. This image shows winging of the scapula. Winging of the scapula, also known as
scapular winging, is a condition characterized by the abnormal protrusion or prominence of the scapula away from the back wall of the thorax. Normally, the scapula lies flat
against the rib cage, providing stability and support for arm movements.

A. Temperature 37.5° C (99.5° F) B. Client is difficult to arouse. C. Respiratory rate 10/min D. Pulse oximetry 88% on room air (95% to 100%) E. Pupils are 3 mm, equal, and reactive to light. Blood pressure 99/46 mm Hg F. Heart rate 61/min

Correct Answer is ["B","C","D"]

Explanation

A. A temperature of 37.5° C (99.5° F) is slightly elevated but can be expected postoperatively and does not typically require immediate intervention.
B. The client being difficult to arouse is concerning following opioid administration, as it may indicate over-sedation or the onset of respiratory depression. This requires immediate nursing action.
C. A respiratory rate of 10/min is low and can be a sign of opioid-induced respiratory depression, especially when combined with difficulty arousing the client. This is a critical value that
necessitates prompt nursing assessment and intervention.

D. Pulse oximetry of 88% on room air is below the normal range and indicates hypoxemia. This is a serious finding that requires immediate action to improve the client's oxygenation.

E. Pupils that are 3 mm, equal, and reactive to light, along with a blood pressure of 99/46 mm Hg, while on the lower side, are not as immediately concerning as the respiratory rate and level of consciousness.
F. A heart rate of 61/min is within normal limits and does not typically require intervention unless there are other signs of hemodynamic instability.

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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?

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