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
Correct answer: B
A. "The food is not great, but it is nice not having to do all of my own cooking.":
This statement acknowledges a minor issue with the food but overall expresses satisfaction with the convenience of not having to cook, indicating some level of acceptance of the transition.
B. "I don't want to go to the activity room because none of the other residents can hear."
This statement suggests a feeling of disconnection or dissatisfaction with the activities available in the assisted living facility. The client may be expressing frustration or a sense of isolation because the other residents cannot hear, which could hinder their ability to engage socially and participate in activities. Difficulty accepting the transition may manifest as resistance or reluctance to participate in aspects of facility life, such as group activities, due to perceived limitations or barriers.
C. "The staff sometimes have to remind me to use a cane when I walk in the hall.":
While this statement may indicate some adjustment to the need for assistance or reminders, it does not necessarily suggest difficulty accepting the transition. Instead, it reflects a willingness to comply with safety recommendations provided by the staff.
D. "When I go out, I've been using public transportation since I can't drive anymore":
This statement acknowledges a change in transportation habits due to inability to drive, which may be a practical adaptation to the client's circumstances rather than a sign of difficulty accepting the transition to assisted living.
Correct Answer is D
Explanation
A. Administer metronidazole:
Metronidazole is an antibiotic medication used to treat bacterial infections, particularly those caused by anaerobic bacteria and certain parasites. It is not effective against viral infections like influenza. Administering metronidazole would not prevent the spread of influenza.
B. Don protective eyewear before entering the room:
Protective eyewear is typically worn when there is a risk of exposure to bodily fluids or other potentially infectious materials that could splash or splatter into the eyes. While protective eyewear is an important infection control measure in certain situations, it is not specifically indicated for preventing the spread of influenza, which primarily spreads through respiratory droplets.
C. Place the client in a negative airflow room:
Negative airflow rooms are designed to prevent airborne transmission of infectious agents by maintaining negative air pressure, which prevents contaminated air from flowing out of the room and into adjacent areas. While negative airflow rooms may be used for certain infectious diseases, such as tuberculosis, they are not typically indicated for influenza, which primarily spreads through respiratory droplets. Moreover, negative airflow rooms are often limited in availability and may not be necessary for every client with influenza.
D. Wear a mask when working within 3 feet of the client.
Influenza is primarily spread through respiratory droplets when an infected person coughs, sneezes, or talks. Wearing a mask when working within close proximity (within 3 feet) of the client helps prevent the nurse from inhaling respiratory droplets containing the influenza virus, reducing the risk of transmission. Masks act as a barrier that helps trap respiratory secretions and prevent them from reaching the nurse's mouth and nose.
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