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. "I've never been the kind of person to ask others for help":

This statement indicates that the client may still be struggling with accepting help from others, which suggests that they have not fully adapted to their new situational role. It reflects a reluctance to rely on others and may indicate a desire to maintain independence.

B. "I'm looking forward to being able to be independent again":

While this statement suggests a desire for independence, it does not necessarily indicate that the client has already adapted to their new situational role. It may reflect an aspiration or goal rather than a current state of adaptation.

C. "I really don't know what I'm supposed to do all day":

This statement suggests uncertainty and confusion about how to fill the day, which may indicate difficulty adjusting to the new living arrangement and role. It does not necessarily indicate adaptation but rather a sense of disorientation or discomfort with the current situation.

D. "It's nice having other people cook for me."

This statement suggests that the client has become comfortable with and is accepting of the support provided by their adult child, indicating an adaptation to their new situational role. By expressing appreciation for having others cook for them, the client demonstrates a willingness to rely on and accept assistance from their family member, which is an important aspect of adapting to changes in living arrangements and roles.

A. "I will walk three times per week." B. "I will avoid exposure to the sun." C. "I will decrease my intake of dairy products." D. "I will take 250 milligrams of calcium once per day."

Correct Answer is A

Explanation

A. "I will walk three times per week."

Regular weight-bearing exercises, such as walking, are beneficial for maintaining bone density and reducing the risk of osteoporosis in older adults. Weight-bearing activities help stimulate bone formation and strengthen bones. Therefore, the client's statement about walking three times per week demonstrates an understanding of an effective measure for reducing the risk of osteoporosis.

B. "I will avoid exposure to the sun." - Exposure to sunlight is essential for vitamin D synthesis, which helps the body absorb calcium and maintain bone health. Therefore, avoiding sunlight would not be beneficial for reducing the risk of osteoporosis.

C. "I will decrease my intake of dairy products." - Dairy products are a rich source of calcium, which is crucial for bone health. Decreasing intake of dairy products may lead to inadequate calcium intake, increasing the risk of osteoporosis.

D. "I will take 250 milligrams of calcium once per day." - While calcium supplementation is important for maintaining bone health, the recommended daily intake for older adults is higher than 250 milligrams. The client's statement suggests an inadequate understanding of calcium supplementation for osteoporosis prevention.

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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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