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 D
Explanation
Choice A rationale
Increased collagen is not a factor that would lead to a pressure injury in a client with impaired mobility. Collagen is a protein that helps in the formation of skin and other connective tissues.
Choice B rationale
Decreased serum calcium is not directly related to the development of pressure injuries. While calcium is important for bone health and muscle function, it does not play a direct role in skin integrity.
Choice C rationale
Increased muscle mass is not a risk factor for pressure injuries. In fact, good muscle mass can help distribute pressure more evenly and potentially reduce the risk of pressure injuries.
Choice D rationale
Decreased circulation is a major risk factor for the development of pressure injuries. When blood flow to an area of the body is reduced, the tissues in that area can become deprived of oxygen and nutrients, leading to cell death and the formation of pressure injuries.
Correct Answer is C
Explanation
Choice A rationale
Vibration of the eardrum is not directly transmitted to the eighth cranial nerve, bypassing the inner ear structures. The vibrations from the eardrum are first transmitted through the ossicles (tiny bones in the middle ear) to the cochlea in the inner ear.
Choice B rationale
Sound waves enter the ear canal, but they are not directly converted to electrical impulses. The sound waves cause the eardrum to vibrate, and these vibrations are transmitted through the ossicles to the cochlea, where they are converted into electrical signals that are sent to the brain via the eighth cranial nerve.
Choice C rationale
Vibration of the eardrum transmits through the bony ossicles to the perilymph in the inner ear, stimulating the eighth cranial nerve. This is the correct description of the process of hearing.
Choice D rationale
Sound is not transmitted directly from the eardrum to the brain. The sound-induced vibrations of the eardrum are transmitted through the ossicles to the cochlea, where they are converted into electrical signals that are sent to the brain via the eighth cranial nerve.
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