A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?

Uses one pair of gloves for dressing removal and irrigation

Uses a syringe with a catheter for wound irrigation

Administers an analgesic medication 5 min before starting irrigation

Refrigerates the solution before irrigation

Answer and Explanation

The Correct Answer is B

A. Uses one pair of gloves for dressing removal and irrigation:

It is essential to change gloves between different steps of wound care to prevent cross-contamination and infection. Using the same pair of gloves for dressing removal and irrigation increases the risk of introducing pathogens into the wound, which can lead to infection.

B. Uses a syringe with a catheter for wound irrigation.

Using a syringe with a catheter for wound irrigation allows for controlled and precise delivery of the irrigation solution to the wound site. It helps ensure that the wound is thoroughly cleansed without causing excessive pressure or trauma to the surrounding tissue.

C. Administers an analgesic medication 5 minutes before starting irrigation:

While administering analgesic medication may help alleviate the client's pain during wound irrigation, it is not directly related to the procedural aspect of wound irrigation. Pain management is an essential component of wound care, but it does not demonstrate an understanding of the specific procedure of wound irrigation.

D. Refrigerates the solution before irrigation:

Refrigerating the irrigation solution is not necessary and may cause discomfort to the client when cold solution is used for wound irrigation. Wound irrigation solutions are typically used at room temperature to avoid temperature-related discomfort and to maintain the integrity of the solution.

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Correct Answer is D

Explanation

A. Urinary catheter care:

While urinary catheter care is important for maintaining urinary hygiene and preventing urinary tract infections, it is not as urgent as addressing respiratory needs. If the client is stable and not experiencing acute urinary retention or other urinary complications requiring immediate intervention, urinary catheter care can be performed after addressing respiratory concerns.

B. Wound irrigation:

Wound irrigation is typically performed to clean and debride wounds, promoting healing and preventing infection. While wound care is essential for preventing complications, it is not as urgent as ensuring adequate respiratory function, particularly in a client with an artificial airway requiring suctioning.

C. Enteral feeding:

Enteral feeding is crucial for providing nutrition to clients who cannot consume adequate nutrients orally. However, initiating enteral feeding can wait until the client's respiratory needs are addressed, as the immediate priority is to ensure effective breathing and oxygenation.

D. Endotracheal suctioning

Endotracheal suctioning is a critical procedure performed to clear secretions from the airway, ensuring adequate oxygenation and ventilation in patients with artificial airways such as endotracheal tubes. Maintaining a patent airway is a fundamental aspect of patient care, and suctioning helps prevent airway obstruction, hypoxia, and respiratory distress. Therefore, it takes precedence over other procedures in ensuring the client's respiratory stability and preventing potential complications.

A. "I will use the grab bars when getting in and out of the bathtub." B. "I need to have a fire escape plan with my family." C. "I need to set my hot water heater to 140 degrees Fahrenheit." D. "I will apply tape over frayed areas of electrical cords." E. I need to check my medications for expiration dates."

Correct Answer is ["A","B","E"]

Explanation

A. "I will use the grab bars when getting in and out of the bathtub." - Using grab bars in the bathtub can help prevent slips and falls, promoting safety during bathing.

B. "I need to have a fire escape plan with my family." - Having a fire escape plan is crucial for emergency preparedness and can help ensure the safety of the client and their family in the event of a fire.

C. "I need to set my hot water heater to 140 degrees Fahrenheit." - Setting the hot water heater to 140 degrees Fahrenheit poses a scalding risk, especially for older adults and individuals with sensitive skin. The water heater temperature should be set to a safe and comfortable level, typically between 120 to 130 degrees Fahrenheit, to prevent burns.

D. "I will apply tape over frayed areas of electrical cords." - Applying tape over frayed areas of electrical cords is not a safe practice, as it does not address the underlying issue and may pose a fire hazard. Frayed electrical cords should be replaced promptly to prevent electrical shocks and fires.

E. "I need to check my medications for expiration dates." - Checking medication expiration dates is important to ensure that the medications remain safe and effective for use, reducing the risk of adverse effects or ineffective treatment.

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A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?

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