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 ["B","E","F"]

Explanation

A. Phosphorous level: While phosphorus is important for bone health, deficiencies are rare in individuals with a normal diet and are not typically associated with osteoporosis.

B. Vitamin D level: Vitamin D is essential for calcium absorption and bone health. Inadequate vitamin D levels can lead to decreased calcium absorption and increase the risk of osteoporosis.

C. Smoking history: Smoking is a risk factor for osteoporosis due to its adverse effects on bone metabolism, but the client is a nonsmoker, so this finding does not apply.

D. Alcohol use: Excessive alcohol consumption is a risk factor for osteoporosis, but the client does not drink alcohol, so this finding does not apply.

E. Activity level: A sedentary lifestyle is a risk factor for osteoporosis. Weight-bearing exercises and physical activity help maintain bone density and strength, reducing the risk of osteoporosis.

F. Lactose intolerant: Lactose intolerance may lead to decreased intake of dairy products, which are a significant source of calcium. Inadequate calcium intake can contribute to decreased bone density and increase the risk of osteoporosis.

A. Give the client's medications between meals. B. Assist the client into semi-Fowler's position. C. Encourage the client to use a straw to take the medication D. Administer the client's medications one at a time

Correct Answer is D

Explanation

A. Giving the client's medications between meals:

Administering medications between meals does not address the risk of aspiration associated with dysphagia. Moreover, timing of medication administration in relation to meals may vary depending on the specific medication requirements.

B. Assisting the client into semi-Fowler's position:

While positioning can play a role in facilitating swallowing, semi-Fowler's position alone may not be sufficient to address the risk of aspiration in clients with dysphagia. Moreover, simply positioning the client without considering other factors may not ensure safe medication administration.

C. Encouraging the client to use a straw to take the medication:

Using a straw might not be appropriate for clients with dysphagia as it can increase the risk of aspiration, especially if the client has difficulty controlling the flow of liquid or coordinating swallowing movements.

D. Administer the client's medications one at a time.

Dysphagia refers to difficulty in swallowing, which can increase the risk of choking or aspiration. Administering medications one at a time ensures that each pill is swallowed safely and reduces the risk of aspiration. It allows the nurse to closely monitor the client's ability to swallow each medication and intervene if necessary.

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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

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

Explanation

A nurse is caring for a client who has dysphagia and is receiving oral medications. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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