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 A

Explanation

A. Asking the family if they wish to assist in washing the client's body:

This is an important first step because it respects the family's cultural or religious practices and allows them to participate in the care of their loved one if they choose. It sets the tone for sensitive and respectful postmortem care.

B. Removing the client's dentures for their family to keep:

Dentures are usually leftin the mouth tomaintain facial shape.However, this action is not the first priority.

C. Leaving the client's eyes open until the family views the body:

It is generally recommended to gently close the client's eyes after death as part of the postmortem care process. Leaving the eyes open might be distressing for the family, so this action should not be performed first.

D. Turn overhead lights to a bright setting.

Bright lighting may not be comforting for the family or create a peaceful environment. Dim or soft lighting is usually preferred to create a calming atmosphere during this sensitive time. Therefore, this is not the first action the nurse should take.

A. Ensure that the client's bed is in the lowest position. B. Assess skin temperature and color before applying the restraints. C. Attach the client's restraints toe bed rail. D. Pad bony prominences before applying the restraints. E. Secure restraints to allow three fingers to slide under the restraints

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

Explanation

A. Ensure that the client's bed is in the lowest position.

Keeping the bed in the lowest position helps prevent injury if the client tries to get out of bed, especially when restrained.

B. Assess skin temperature and color before applying the restraints.

This action ensures proper circulation and skin integrity while the restraints are in use. It helps prevent skin breakdown and injury.

C. Attach the client's restraints to the bed rail.

Attaching restraints to the bed rail is not considered a best practice as it can increase the risk of injury to the client. Restraints should be secured to the bed frame or another stable part of the bed to minimize the risk of harm.

D. Pad bony prominences before applying the restraints.

Padding bony prominences such as elbows and wrists helps prevent pressure ulcers and discomfort caused by the restraints.

E. Secure restraints to allow three fingers to slide under the restraints.

Restraints should be secured to allow only two fingers to slide under the restraints to ensure they are not too loose or too tight.

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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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