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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Serum calcium levels are not directly indicative of hypervolemia.

B. A urine specific gravity of 1.001 indicates dilute urine, which is a common finding in hypervolemia as the kidneys attempt to excrete excess fluid.

C. Serum sodium levels within the normal range (e.g., 138 mEq/L) are not indicative of hypervolemia.

D. Urine pH of 6.1 is within the normal range and does not specifically indicate hypervolemia.

A. "Your PICC line will allow long-term access for antibiotic therapy." B. "You should use a 5-milliliter barrel syringe to flush your PICC line at home." C. "Your PICC line must be placed in your nondominant arm." D. "You should immobilize the arm with the PICC line using a sling."

Correct Answer is A

Explanation

A. "Your PICC line will allow long-term access for antibiotic therapy." - PICC lines are often used for long-term administration of medications, including antibiotics, due to their durability and ease of use.

B. "You should use a 5-milliliter barrel syringe to flush your PICC line at home." - The size of the syringe used to flush a PICC line depends on the facility's protocol and the client's specific

needs. Specific instructions regarding syringe size should be provided by the healthcare provider or nurse.

C. "Your PICC line must be placed in your nondominant arm." - The choice of arm for PICC line placement depends on various factors, including vein integrity and the client's comfort. There is no strict requirement for the PICC line to be placed in the nondominant arm.

D. "You should immobilize the arm with the PICC line using a sling." - Immobilizing the arm with a sling is not typically necessary after PICC line placement. Clients are usually instructed to avoid excessive movement and to keep the arm clean and dry to prevent complications.

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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?

Nursing Test Bank

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