A nurse is preparing to irrigate a wound for a client.
Which of the following actions should the nurse plan to take?
Hold the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating.
Chill the irrigant prior to the procedure.
Flush the wound from the most contaminated area to the cleanest area.
Irrigate the wound until the solution that is draining is clear.
The Correct Answer is D
Choice A rationale:
Holding the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating is not the best practice for wound irrigation. It's crucial to maintain a close distance to the wound to ensure that the irrigation solution effectively cleans the area.
Choice B rationale:
Chilling the irrigant prior to the procedure is not necessary and could be uncomfortable for the patient. Room temperature or slightly warmed sterile saline solution is typically used for wound irrigation to prevent temperature-related discomfort.
Choice C rationale:
Flushing the wound from the most contaminated area to the cleanest area is an incorrect approach for wound irrigation. The wound should be irrigated from the cleanest to the most contaminated to prevent contamination of previously clean areas and ensures thorough cleaning of the wound.
Choice D rationale:
Irrigating the wound until the solution that is draining is clear is a common practice for wound irrigation. It indicates that the wound is free of contaminants, debris, and infectious material.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is d. "Seeing spots is a manifestation of diabetic retinopathy."
Choice A rationale:
- Clouding of the lens is not a manifestation of diabetic retinopathy.It is a characteristic of cataracts,a condition that involves a different eye structure and has a different etiology.
- Diabetic retinopathy specifically affects the retina,which is the light-sensitive tissue lining the back of the eye.It does not directly involve the lens.
- It's crucial to clarify this distinction for the client to ensure accurate understanding of their condition and potential symptoms.
Choice B rationale:
- Increased intraocular pressure is not the cause of diabetic retinopathy.It is the primary feature of glaucoma,another eye condition with distinct causes and consequences.
- Diabetic retinopathy is primarily driven by damage to the blood vessels in the retina due to prolonged high blood sugar levels.
- Explaining this difference to the client can help prevent confusion and promote appropriate preventive measures.
Choice C rationale:
- While regular eye exams are essential for early detection and management of diabetic retinopathy,the recommended frequency is more often than every 2 years.
- The American Diabetes Association recommends that individuals with diabetes have a comprehensive dilated eye exam at least annually.
- More frequent exams may be necessary depending on the individual's risk factors and the severity of their diabetes.
Choice D rationale:
- Seeing spots is a common and significant symptom of diabetic retinopathy.It occurs when blood vessels in the retina leak fluid or bleed,causing disruptions in vision.
- Other potential symptoms of diabetic retinopathy include:
- Blurred vision
- Floaters (dark specks or strings that move across the visual field)
- Difficulty seeing at night or in low light
- Loss of central vision
- Distortion of colors
- Blind spots
Correct Answer is C
Explanation
Choice A rationale:
"Apply lotion between the toes.”. Applying lotion between the toes is not a recommended practice for individuals with diabetic neuropathy. The rationale for this is that excess moisture between the toes can create an environment conducive to fungal infections, which individuals with diabetes are more susceptible to due to compromised immune function and poor circulation.
Choice B rationale:
"Wear open-toed shoes.”. Wearing open-toed shoes is generally not recommended for individuals with diabetic neuropathy. Open-toed shoes expose the feet to potential injury and do not provide adequate protection. It's essential to wear closed-toed, well-fitting shoes to prevent foot injuries and complications.
Choice C rationale:
"Avoid walking barefoot.”. The correct answer, "Avoid walking barefoot," is a crucial instruction for individuals with diabetic neuropathy. Walking barefoot increases the risk of injury, as patients with neuropathy may not feel pain or discomfort from small cuts or injuries to their feet. It is essential to protect the feet by wearing shoes or slippers to minimize the risk of wounds and infections.
Choice D rationale:
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