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. Check the pH level of the client's gastric contents:

Checking the pH level of gastric contents is not typically necessary before administering intermittent tube feeding. pH testing of gastric contents is more commonly performed for clients with nasogastric tubes to confirm tube placement within the stomach. It is not routinely done before administering tube feeding through a percutaneous gastrostomy tube.

B. Check the patency of the client's tube every 8 hr:

While it is essential to check the patency of the tube regularly, every 8 hours may not be frequent enough, especially for clients receiving intermittent tube feedings. Tube patency should be checked before and after each feeding or medication administration to ensure proper function and prevent complications.

C. Place the client in a supine position:

Placing the client in a supine position is not specifically indicated for administering intermittent tube feedings. The client's position during tube feeding administration depends on individual factors such as comfort, mobility, and risk of aspiration. The nurse should position the client in a semi-upright or upright position (typically at a 30-45 degree angle) to reduce the risk of aspiration.

D. Flush the client's tube with 5 mL of water.

Flushing the client's tube with water helps ensure its patency and removes any residual feeding solution or gastric contents, reducing the risk of clogging and infection. Flushing with 5 mL of water is a common practice to maintain tube patency and should be done before and after each feeding and medication administration.

A. Family history B. Fasting glucose level C. History of hyperlipidemia D. History of rheumatoid E. History of hypertension F. Cholesterol level

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

Explanation

A. Family history: A family history of heart disease can increase an individual's risk of developing heart disease themselves, as genetic factors play a role in cardiovascular conditions.

B. Fasting glucose level: Elevated fasting glucose levels, indicative of diabetes or prediabetes, can contribute to heart disease risk. Diabetes is a significant risk factor for heart disease and can lead to complications such as atherosclerosis and coronary artery disease.

C. History of hyperlipidemia: Hyperlipidemia refers to elevated levels of lipids (cholesterol and triglycerides) in the blood. High levels of LDL cholesterol ("bad" cholesterol) and low levels of HDL cholesterol ("good" cholesterol) are associated with an increased risk of heart disease.

D. History of rheumatoid arthritis: Rheumatoid arthritis is an autoimmune condition that involves inflammation in the joints. Chronic inflammation associated with rheumatoid arthritis can affect blood vessels and increase the risk of heart disease and cardiovascular events.

E. History of hypertension: Hypertension, or high blood pressure, is a major risk factor for heart disease. It puts added strain on the heart and blood vessels, increasing the risk of atherosclerosis, heart attacks, and other heart-related complications.

F. Cholesterol level: Elevated levels of LDL cholesterol ("bad" cholesterol) and triglycerides, as well as low levels of HDL cholesterol ("good" cholesterol), are associated with an increased risk of heart disease.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer intermittent tube feeding to a client who has a percutaneous gastrostomy tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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

Explanation

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