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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Swing-through gait:
The swing-through gait is a more advanced gait pattern used by clients with significant lower extremity weakness or paralysis. It involves swinging both crutches forward simultaneously, followed by swinging both legs forward past the crutches. This gait is not appropriate for a client who can only bear weight on one leg.
B. Three-point gait:
The three-point gait is typically used when one lower extremity is completely non-weight-bearing. It involves advancing both crutches and then swinging the affected leg through to meet the crutches. Since the client in this scenario can bear weight on one leg, the three-point gait is the most appropriate choice.
C. Four-point alternating gait
Four-point alternating gait
The four-point alternating gait involves a sequence of movements where each crutch and each leg move alternately. The sequence is as follows:
- Move the right crutch forward(injured side).
- Move the left foot forward(non-injured side).
- Move the left crutch forward(non-injured side).
- Move the right foot forward(injured side). This gait offers stability and control but requires more effort and coordination.
D. Two-point alternating gait:
The two-point alternating gait involves moving one crutch and the opposite lower extremity forward simultaneously, followed by moving the other crutch and the opposite lower extremity forward. This gait pattern is typically used by clients who have good balance and strength in both lower extremities. It may not provide enough stability and support for a client who can only bear weight on one leg.
Correct Answer is A
Explanation
A. "Walk for 30 minutes three to five times each week."
Regular weight-bearing exercises, such as walking, are beneficial for maintaining bone density and reducing the risk of osteoporosis. Walking for 30 minutes three to five times per week can help strengthen bones, improve balance, and reduce the risk of fractures associated with osteoporosis.
B. "Perform water aerobics three times each week": While water aerobics is a beneficial form of exercise for overall health and fitness, it may not be as effective as weight-bearing exercises like walking for preventing osteoporosis. Water-based activities do not provide the same impact on bone density as weight-bearing exercises.
C. "Maintain a lean body mass": While maintaining a healthy body weight is important for overall health, particularly for reducing the risk of conditions like heart disease and diabetes, it may not specifically prevent osteoporosis. In fact, having a low body weight or being underweight can increase the risk of osteoporosis.
D. "Increase intake of vitamin B12": Vitamin B12 is important for various bodily functions, including nerve function and the formation of red blood cells, but it is not directly linked to the prevention of osteoporosis. Adequate calcium and vitamin D intake, along with weight-bearing exercise, are key factors in preventing osteoporosis.
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