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.

Answer and Explanation

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.

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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.

A. Open the outside cover of the sterile kit and remove the dust cover B. Grasp the outermost flap of the sterile kit while opening away from the body. C. Prepare a dry work surface above the waist level D. Open the innermost lower flap of the sterile kit while standing away from the sterile field E. Open each side flap of the sterile kit individually while pulling to the side

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

Explanation

A. Opening the outside cover of the sterile kit and removing the dust cover exposes the sterile supplies within the kit.
B. Grasping the outermost flap of the sterile kit while opening away from the body helps maintain the sterility of the contents within the kit.

C. Preparing a dry work surface above the waist level ensures that the sterile field is established at a proper height and that the nurse's hands are at the appropriate level for working within the sterile field.
D. Opening the innermost lower flap of the sterile kit while standing away from the sterile field allows the nurse to access the sterile supplies without contaminating the sterile field.
E. Opening each side flap of the sterile kit individually while pulling to the side further establishes the sterile field and provides access to the sterile supplies.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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