A nurse is assisting in the care of a client who is prescribed wound irrigation after abdominal surgery. Which of the following should the nurse identify as proper technique?
Fill a 20 mL syringe with irrigation solution.
Hold the syringe 7.5 cm (3 in) above the wound.
Allow solution to flow from the least to the most contaminated area.
Use fast and continuous pressure when flushing the wound.
The Correct Answer is C
A. Fill a 20 mL syringe with irrigation solution: Small syringes, like 20 mL, generate excessive pressure that can damage healing tissue. A 30–60 mL syringe is typically recommended to provide safe, gentle irrigation without traumatizing the wound.
B. Hold the syringe 7.5 cm (3 in) above the wound: Proper irrigation technique requires holding the syringe close enough to allow controlled flow but not so high as to increase pressure. Typically, the syringe tip is held just above the wound, about 1–2 inches, to avoid tissue injury.
C. Allow solution to flow from the least to the most contaminated area: Directing irrigation from clean to contaminated areas prevents introduction of pathogens into healthy tissue and reduces infection risk. This is a key principle of aseptic wound care.
D. Use fast and continuous pressure when flushing the wound: High-pressure or rapid irrigation can damage granulation tissue and delay healing. Gentle, controlled pressure ensures debris is removed without harming the wound bed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Reviewing the results of the client's celiac screening with their parents, without the client's consent: Routine pediatric screenings for general health conditions, such as celiac disease, are typically shared with parents because they are involved in the minor’s overall medical care. This does not constitute a breach of confidentiality.
B. Reviewing the results of the client's chlamydia screening with their parents, without the client's consent: Sexually transmitted infection (STI) testing is confidential for adolescents in most jurisdictions. Sharing these results with parents without the minor’s consent violates the client’s legal and ethical right to privacy.
C. Reviewing the results of the client's complete blood count (CBC) with their parents, without the client's consent: Routine lab results like a CBC can usually be shared with parents for adolescents under 18, as they are part of standard health monitoring. This is generally not considered a breach of confidentiality.
D. Reviewing the results of the client's urinalysis with their parents, without the client's consent: Urinalysis results for general health purposes can typically be shared with parents. Confidentiality concerns mainly arise when the test relates to sensitive conditions, such as STIs or reproductive health.
Correct Answer is B
Explanation
A. "The important thing is that he gets better, not how long it takes.": This response dismisses the partner’s concern about timing and does not provide guidance or education. It avoids addressing the question and may increase anxiety or frustration.
B. "Tell me what you know about depression.": Asking this encourages the partner to share their understanding, allowing the nurse to identify misconceptions and provide individualized education about the course of depression, expected timeline for improvement, and treatment strategies. It fosters engagement and supports informed caregiving.
C. "We've seen steady improvement in other clients who are depressed.": While intended to reassure, this statement generalizes experiences and may create unrealistic expectations. Recovery timelines vary widely among individuals with depression.
D. "No one really knows the answer to that question.": This response is dismissive and provides no guidance or support. It fails to educate or empower the partner to participate in care or recognize signs of improvement.
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