A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

A. Syringe with a catheter is not typically used for wound irrigation. A syringe is often used alone, typically with a sterile tip to apply pressure when irrigating the wound, which helps remove debris, bacteria, and dead tissue. However, a catheter is not typically involved in the process unless specifically required for certain types of drainage or if a very specialized approach is needed.
B. Refrigerating the solution before irrigation is not typically necessary for wound irrigation. While some solutions may be stored in the refrigerator for preservation, they should be brought to room temperature before use to prevent discomfort to the client and to avoid potential thermal injury to the wound.
C. Using one pair of gloves for dressing removal and irrigation is not recommended as it can lead to contamination of the irrigation solution and increase the risk of infection. Standard precautions dictate that gloves should be changed after performing wound debridement or dressing removal to prevent cross-contamination.
D. This is an appropriate action for the nurse to take because wound irrigation, especially for painful conditions like pressure injuries, can cause discomfort. Administering an analgesic before starting the procedure helps ensure that the client is comfortable and that pain is minimized during the process.

B. Securing the tracheostomy tube in place with a collar that has hook-and-loop fasteners is a common and effective method. This type of collar provides secure support while allowing for easy adjustment and removal as needed for tracheostomy care. It helps prevent accidental dislodgement of the tracheostomy tube and provides stability for the client.
C. When providing tracheostomy care, it is crucial to maintain a sterile environment to prevent infection. The appropriate steps include wearing sterile gloves while handling the inner cannula and cleaning it with a sterile solution.
A. Placing a gauze pad under the flanges of the tracheostomy tube is not a recommended practice. The use of gauze pads under the flanges can increase the risk of infection, interfere with the proper fit and function of the tracheostomy tube, and cause pressure ulcers or skin irritation.
D. Using full-strength hydrogen peroxide to cleanse the skin around the stoma is not recommended. Hydrogen peroxide can be irritating to the skin, cause tissue damage, and delay wound healing. Instead, the nurse should use a mild, non-irritating antiseptic solution or sterile saline to cleanse the skin around the stoma.