The graduate nurse is performing a sterile wound irrigation. What action indicates correct understanding of the technique?
Dispose used gauze and supplies in appropriate receptacle.
Apply prescribed sterile dressing to wound bed if packing is prescribed.
Stop the irrigation once the wound solution flows clear.
Perform hand hygiene after removing all PPE.
The Correct Answer is C
A. Dispose used gauze and supplies in appropriate receptacle: While proper disposal of contaminated supplies is important for infection control, it does not demonstrate understanding of the sterile wound irrigation technique itself. This action is part of standard post-procedure cleanup rather than the key procedural step.
B. Apply prescribed sterile dressing to wound bed if packing is prescribed: Applying a sterile dressing is part of wound care management, but it occurs after irrigation and does not directly reflect the nurse’s technique or knowledge in performing the irrigation correctly.
C. Stop the irrigation once the wound solution flows clear: Correct sterile wound irrigation involves continuing the process until the irrigating solution is free of debris and exudate, ensuring that contaminants, necrotic tissue, or drainage are effectively removed. This demonstrates proper technique and promotes optimal wound healing while maintaining sterility.
D. Perform hand hygiene after removing all PPE: Performing hand hygiene is a standard infection control measure, essential for safety but unrelated to demonstrating competence in the sterile irrigation technique. It is a general practice rather than a key indicator of correct procedural performance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
Calculation:
The question asks for the volume of acetaminophen to administer in mL.
- Identify the ordered dose and available concentration
Ordered Dose: 320 mg
Available: 160 mg/5 mL
- Calculate the volume to administer
Volume (mL) = (Ordered Dose ÷ Available Dose) × Quantity
Volume = (320 ÷ 160) × 5
Volume = 2 × 5
= 10 mL
Correct Answer is ["A","D"]
Explanation
A. Full thickness skin loss of the subcutaneous tissue: Stage 3 pressure injuries involve full-thickness loss of the skin extending through the dermis into the subcutaneous tissue. The subcutaneous fat may be visible, and the depth of the wound varies by anatomical location, making this a defining characteristic of Stage 3 injuries.
B. A deep purplish area is noted: A deep purplish or maroon area is more characteristic of a suspected deep tissue injury rather than a Stage 3 pressure injury. These injuries involve underlying tissue damage beneath intact or minimally broken skin and may not involve full-thickness loss of subcutaneous tissue at this stage.
C. A shallow wound bed is present: Shallow wounds are typical of Stage 2 pressure injuries, which involve partial-thickness loss of dermis and present as open, superficial ulcers. Stage 3 wounds are deeper and extend through the full thickness of the skin into subcutaneous tissue.
D. No visible bone, tendon, and ligaments are noted: In Stage 3 pressure injuries, the bone, tendon, or muscle is not exposed. The injury extends into subcutaneous tissue but stops short of deeper structures, distinguishing it from Stage 4 pressure injuries.
E. Visible bone, tendon, and ligaments are noted: Exposure of bone, tendon, or ligaments indicates a Stage 4 pressure injury, which involves full-thickness tissue loss with damage extending into underlying structures. This finding exceeds the depth seen in Stage 3 injuries.
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