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 D
Explanation
Rationale:
A. A fever may influence the result of an oxygen saturation test but is not a direct factor.
B. An elevated hemoglobin level is unlikely to influence the result of an oxygen saturation test.
C. Wearing a ring is unlikely to influence the result of an oxygen saturation test.
D. Wearing nail polish can interfere with the accuracy of pulse oximetry readings by causing an inaccurate reflection of light, leading to a falsely low oxygen saturation reading.
Correct Answer is A,D,B,C,E
Explanation
A. Unlock and remove the inner cannula is the first step because it allows access to the inner cannula for cleaning.
B. Scrub the inside and outside of the inner cannula with a small brush is the third step because it removes debris and secretions from the inner cannula.
C. Wipe the inside of the inner cannula with a folded pipe cleaner is the fourth step because it further cleans the inner cannula.
D. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin is the second step because it provides the solution for cleaning the inner cannula.
E. Cleanse the stoma site with 0.9% sodium chloride solution is the final step because it cleans the stoma site before replacing the inner cannula.
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