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 C

Explanation

If the nurse suspects the catheter is not in the urethra, they should leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.

A. Discard the dressing in the bedside trash receptacle. B. Double-bag the dressing in clear bags and label it “biohazard”. C. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. D. Dispose of the dressing in a biohazardous waste container.

Correct Answer is D

Explanation

Choice A rationale

Discarding the dressing in the bedside trash receptacle is not recommended because it can lead to the spread of infection. The dressing is contaminated with blood and purulent drainage, which are considered biohazardous waste.

Choice B rationale

Double-bagging the dressing in clear bags and labeling it “biohazard” is not sufficient. While it’s important to label biohazardous waste, the dressing should be disposed of in a designated biohazardous waste container.

Choice C rationale

Enclosing the dressing in a single clear plastic bag and discarding it in the bedside trash receptacle is also not recommended. This method does not provide adequate containment for biohazardous waste.

Choice D rationale

Disposing of the dressing in a biohazardous waste container is the correct method. This ensures that the biohazardous waste is properly contained and reduces the risk of spreading infection.

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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 inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?

Correct Answer is C

Explanation

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Correct Answer is D

Explanation

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