When irrigating a draining wound with a sterile saline solution, the nurse should follow what correct sequence of actions?
Remove soiled dressing, flush wound, and wash hands.
Pour solution, wash hands, and remove soiled dressing.
Wash hands, prepare sterile field, and apply clean gloves for dressing removal.
Prepare sterile field, put on sterile gloves, and remove soiled dressing.
The Correct Answer is C
Choice A rationale
Removing a soiled dressing before washing hands and preparing the environment is a violation of infection control principles. The nurse's hands could be contaminated from other tasks, and touching a wound site without prior hygiene increases the risk of healthcare-associated infections. Furthermore, flushing the wound before having a clean field ready can lead to contamination of the surrounding area. The sequence must begin with hand hygiene and proper preparation of the sterile field to ensure safety.
Choice B rationale
Pouring the solution before washing hands or removing the old dressing is disorganized and risks contaminating the sterile solution. If the nurse pours the solution first, it sits exposed to the air while the contaminated dressing is handled, increasing the risk of airborne pathogens settling in the liquid. Hand hygiene must always be the very first step in any sterile or clean procedure to minimize the transfer of microorganisms from the nurse to the client or equipment.
Choice C rationale
The correct sequence begins with washing hands to reduce the microbial load on the nurse. Next, the nurse prepares the sterile field to ensure all necessary supplies are ready and uncontaminated. Applying clean gloves to remove the old, soiled dressing protects the nurse from pathogens in the wound drainage. After removal, the nurse discards the contaminated gloves and performs hand hygiene again before donning sterile gloves for the irrigation. This flow maintains the highest standard of surgical asepsis.
Choice D rationale
Preparing the sterile field and putting on sterile gloves before removing the soiled dressing is incorrect because the sterile gloves would become contaminated the moment they touch the old dressing. Removing a soiled dressing is a "clean" task, not a "sterile" one. Once the old dressing is gone and the area is cleaned, the nurse should then transition to sterile gloves for the actual irrigation and application of the new sterile dressing to prevent cross-contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Excoriated skin is a significant concern due to the enzymes and acidity found in liquid stool, which can lead to rapid skin breakdown in the perianal area. While painful and a risk for secondary infection, it is usually localized and not immediately life-threatening. Proper barrier creams and hygiene can manage this issue. While important for nursing care, it does not carry the same systemic urgency as the loss of vital body fluids.
Choice B rationale
Malnutrition can occur if diarrhea is chronic, as rapid transit time through the intestines prevents the adequate absorption of nutrients, vitamins, and minerals. However, malnutrition is typically a slow-developing complication rather than an acute physiological emergency. In the context of a client currently experiencing diarrhea, the nurse must prioritize immediate stability over long-term nutritional status. Acute fluid loss poses a much more immediate threat to the client's physiological homeostasis.
Choice C rationale
Urinary incontinence is generally not a direct physiological result of diarrhea, although the urgency of diarrhea might cause accidental soiling. While it presents a challenge for hygiene and comfort, it is not a physiological response that threatens the client's vital signs or organ function. The nurse should address incontinence through frequent rounding and skin care, but it remains a lower priority compared to the systemic effects of significant fluid and electrolyte depletion.
Choice D rationale
Dehydration is the most critical concern because diarrhea involves the rapid loss of water and essential electrolytes like potassium and sodium. Severe dehydration leads to decreased circulating blood volume, which can cause hypotension, tachycardia, and potentially hypovolemic shock. Normal fluid balance is essential for cellular function and organ perfusion. Because diarrhea bypasses the large intestine's ability to reabsorb water, the risk of rapid systemic collapse makes dehydration the primary nursing priority.
Correct Answer is B
Explanation
Choice A rationale
Inspecting the mouth is an important aspect of overall hygiene and monitoring for oral candidiasis or dryness related to oxygen therapy, but it does not address the most immediate physical risk of the nasal cannula apparatus itself. While the mouth should be assessed regularly, every 24 hours is a generic interval that might miss early signs of mucosal irritation or other complications in a client with chronic obstructive respiratory disease.
Choice B rationale
Nasal cannulas exert constant pressure and friction on the sensitive skin of the nares and behind the ears. For clients with chronic respiratory issues, skin integrity is a priority because breakdown can lead to infection and discomfort, potentially decreasing compliance with oxygen therapy. Assessing the nares every 8 hours allows for early detection of redness or pressure ulcers, which is standard nursing practice for maintaining skin integrity in patients using external medical devices.
Choice C rationale
Checking oxygen flow and pulse oximetry every 48 hours is dangerously infrequent for a client with a chronic obstructive respiratory disease. These clients require frequent monitoring to ensure they are maintaining adequate saturation, typically between 88.
Choice D rationale
Checking the patency of the cannula only once every 24 hours is insufficient for ensuring continuous and effective oxygen delivery. Cannulas can easily become dislodged, kinked, or clogged with nasal secretions, leading to a sudden drop in the fraction of inspired oxygen. Frequent checks of the equipment are necessary to ensure the client receives the prescribed flow rate, especially since these clients rely on supplemental oxygen to maintain baseline metabolic functions and prevent exacerbations.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.