A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
Cleanse the wound with cotton balls.
Use a 10-mL syringe filled with cleansing solution.
Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
Dry the wound bed with gauze squares.
The Correct Answer is C
A. Cleanse the wound with cotton balls – Cotton fibers can shed and leave debris in the wound, increasing the risk of infection. Gauze or irrigation is preferred.
B. Use a 10-mL syringe filled with cleansing solution – A 10-mL syringe does not provide sufficient pressure for effective irrigation. A 30- to 60-mL syringe is typically recommended.
C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound – This ensures appropriate pressure and prevents contamination while effectively flushing out debris.
D. Dry the wound bed with gauze squares – The wound bed should be kept moist to promote healing; only the surrounding skin should be dried if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Squeezing the client's finger can cause hemolysis and affect test accuracy.
B. Pricking the side of the finger is recommended because it is less painful and provides better blood flow.
C. Keeping the hand below heart level promotes better blood flow; elevating it can reduce blood flow.
D. Alcohol is preferred for cleansing; iodine can interfere with test results.
E. Wearing clean gloves is necessary for infection control and safety.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
A. Physical therapy for muscle-strengthening and balance-training is expected because the client has a left lateral malleolus fracture and a Bone Mineral Density DEXA scan of -3.8. Physical therapy can help with rehabilitation and prevent future falls.
B. Calcium supplementation is expected because the client has a Bone Mineral Density DEXA scan of -3.8, indicating osteoporosis. Calcium supplementation is essential for bone health.
C. Vitamin D supplementation is expected because the client has a Bone Mineral Density DEXA scan of -3.8, indicating osteoporosis. Vitamin D supplementation is essential for calcium absorption and bone health.
D. A home health evaluation of home safety is expected because the client lives alone and has a history of falling. A home health evaluation can help identify potential hazards and improve safety.
E. Increasing caffeine intake is unexpected because the client already reports consuming at least 3 cups of coffee daily. Increasing caffeine intake further may not be advisable due to potential side effects, such as increased heart rate and blood pressure.
F. Increasing daily sun exposure is unexpected because the client has osteoporosis and a history of falling. Excessive sun exposure can increase the risk of skin cancer, and the client may not be able to safely spend extended periods of time in the sun due to mobility limitations. Additionally, vitamin D supplementation is usually recommended over sun exposure for individuals with osteoporosis.
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