A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the newly licensed nurse understands wound irrigation?
Cleanses the wound with povidone-iodine on cotton balls
Administers PO analgesia 20 min prior to irrigation
Warms the irrigation solution in the microwave oven prior to application
Irrigates the wound from the top to the bottom
The Correct Answer is D
A. Povidone-iodine may be used as a wound cleanser, but the method described here (using cotton balls) is not typically recommended as it can leave fibers in the wound.
B. Administering oral analgesia prior to wound irrigation may be appropriate for pain management but is not directly related to understanding wound irrigation technique.
C. Warming irrigation solution in a microwave oven can lead to uneven heating and potential tissue damage. This method is not recommended for warming irrigation solution.
D. Irrigating the wound from the top to the bottom ensures that contaminants are flushed away from the wound site, reducing the risk of infection and promoting healing. This indicates an understanding of proper wound irrigation technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Speaking directly into one of the client's ears may be ineffective if the client has bilateral hearing impairment or if the hearing impairment is not related to the ear anatomy.
B. Rephrasing sentences the client does not understand can help clarify communication and ensure the client receives necessary information.
C. Dropping voice volume at the end of sentences can make it difficult for the client to hear the entire message, especially if the client relies on lip-reading or amplification devices.
D. Exaggerating lip movements may not be helpful for all clients with hearing impairment and may not accurately convey the intended message. Instead, clear and natural lip movements should be used along with other communication strategies such as rephrasing sentences and facing the client directly.
Correct Answer is B
Explanation
A. The wall suction setting does not directly indicate the functioning of the NG tube.
B. Greenish-yellow drainage fluid may indicate the presence of bile in the stomach, suggesting
that the NG tube is not adequately draining gastric contents, which could indicate a malfunction.
C. An aspirate pH of 3 indicates gastric acidity, which is expected in the stomach and does not necessarily indicate a problem with NG tube function.
D. Abdominal rigidity may suggest intra-abdominal pathology but does not specifically indicate NG tube dysfunction.
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