A nurse is preparing to irrigate a wound for a patient. What actions should the nurse plan to take?
Chill the irrigant prior to the procedure.
Irrigate the wound until the solution that is draining is clean.
Hold the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating.
Flush the wound from the most contaminated area to the cleanest area.
The Correct Answer is B
Choice A rationale
Chilling the irrigant prior to the procedure is not recommended. Cold irrigant can cause discomfort and potentially lead to vasoconstriction, which can impede the healing process.
Choice B rationale
Irrigating the wound until the solution that is draining is clean is a standard practice in wound care. This helps to ensure that all debris and potential contaminants are removed from the wound.
Choice C rationale
Holding the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating is not a standard practice. The syringe should be held close to the wound to ensure effective irrigation.
Choice D rationale
Flushing the wound from the most contaminated area to the cleanest area is not a standard practice. The wound should be irrigated from the cleanest to the dirtiest area to prevent the spread of contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A black pressure ulcer indicates necrotic tissue, which often requires surgical debridement.
Choice B rationale
Increased drainage from the wound is not typically associated with a black pressure ulcer.
Choice C rationale
While documenting the wound status daily is part of wound care, it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.
Choice D rationale
Increased monitoring of the wound condition is part of wound care, but it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.
Correct Answer is C
Explanation
Choice A rationale
Detecting the scent of a rose is primarily associated with the olfactory system, not the tactile system.
Choice B rationale
Observing the color of a flower is primarily associated with the visual system, not the tactile system.
Choice C rationale
Feeling the texture of a fabric is primarily associated with the tactile system. The tactile system, part of the somatosensory system, allows us to perceive touch, pressure, temperature, pain, and vibration.
Choice D rationale
Hearing the sound of a bell is primarily associated with the auditory system, not the tactile system.
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