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.

Answer and Explanation

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.

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Correct Answer is AANDD

Explanation

Choice A rationale

An ileostomy involves creating a stoma, or opening, in the abdominal wall. The location of the stoma is typically in the right lower abdomen.

Choice B rationale

The end of the stoma should not be painful after the procedure. If the patient experiences pain, it could indicate a complication and should be reported to the healthcare provider.

Choice C rationale

The patient should not expect the stoma to be a purple color. A healthy stoma should be red or pink. A purple stoma could indicate a lack of blood flow, which is a serious issue that needs immediate medical attention.

Choice D rationale

After an ileostomy, the patient will have liquid or semi-liquid stool pass through the stoma. This is because the large intestine, which normally absorbs water and forms solid stool, is bypassed or removed in the procedure.

A. Wet-to-dry dressings B. Surgical debridement C. Enzymatic debridement D. Autolytic debridement

Correct Answer is A

Explanation

Choice A rationale: Wet-to-dry dressings are a form of mechanical debridement. This method involves applying a wet dressing to the wound and allowing it to dry. When the dressing is removed, it also removes some of the dead or damaged tissue from the wound, helping to clean the wound and promote healing. This method can be painful and is not selective, meaning it can also remove healthy tissue. However, it is often used for wounds with a large amount of debris or necrotic tissue.

Choice B rationale: Surgical debridement is another method of wound debridement, but it is not a form of mechanical debridement. This method involves using surgical instruments to remove dead or damaged tissue. It is the fastest method of debridement and is often used for wounds that are infected or have a large amount of necrotic tissue. However, it requires a skilled practitioner and can be painful.

Choice C rationale: Enzymatic debridement involves applying a topical ointment that contains enzymes to the wound. These enzymes help to break down dead or damaged tissue. This method is selective and only removes necrotic tissue, leaving healthy tissue intact. However, it is not a form of mechanical debridement.

Choice D rationale: Autolytic debridement is a method that uses the body’s own enzymes and moisture to break down dead or damaged tissue. This is the slowest method of debridement but is also the least painful and is selective for necrotic tissue. Like enzymatic debridement, autolytic debridement is not a form of mechanical debridement.

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A nurse is preparing to irrigate a wound for a patient. What actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?

Correct Answer is AANDD

Explanation

The same nurse is now preparing to clean the abrasion on the client’s right elbow. The provider has prescribed mechanical debridement for the wound. Exhibits Which of the following is a form of mechanical debridement that the nurse should expect to use?

Correct Answer is A

Explanation

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