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
Explanation
Rationale:
A. A stoma that protrudes slightly from the abdomen is normal after colostomy surgery.
B. A stoma that appears dark in color may indicate compromised blood flow and should be reported to the provider.
C. A stoma that bleeds lightly when touched is normal after colostomy surgery.
D. A stoma that is draining a small amount of liquid stool is normal after colostomy surgery.
Correct Answer is ["12.5"]
Explanation
To calculate the dose of ampicillin for a school-age child who weighs 55 lb, follow these steps: Convert the weight from pounds to kilograms:
55 lb × 1 kg/2.2 lb = 25 kg
Calculate the total daily dose of ampicillin:
50 mg/kg/day × 25 kg = 1250 mg/day
Divide the total daily dose by the number of doses per day:
1250 mg/day ÷ 4 doses/day = 312.5 mg/dose
Convert the dose from milligrams to milliliters using the concentration of the oral suspension:
312.5 mg/dose ÷ 125 mg/5 mL = 12.5 mL/dose
So, the nurse should administer approximately 12.5 mL of ampicillin oral suspension with each dose.
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