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. Apply oxygen at 3 L/min per nasal cannula: While oxygenation is important, there is no
indication in the scenario that the client requires oxygen supplementation at this time. Checking oxygen saturation would be more relevant if there were respiratory concerns.
B. Review the chest x-ray report: This is the most appropriate action before initiating the IV
infusion to ensure proper placement of the central venous catheter and absence of complications such as pneumothorax or malposition.
C. Flush the catheter with sterile water: Flushing the catheter with sterile water is not necessary before starting the infusion, especially without confirming proper catheter placement through chest x-ray.
D. Obtain a peripheral blood glucose level: While monitoring blood glucose levels may be
important in certain clinical situations, it is not directly relevant to initiating an IV infusion of Ringer's lactate via a central venous catheter.
Correct Answer is A
Explanation
- A) Hyperreflexia is a common symptom of opioid withdrawal, as the nervous system reacts to the absence of the drug. Patients may experience increased reflex actions and muscle spasms due to the sudden change in opioid levels.
- B) Meiosis, or pupil constriction, is not typically a withdrawal symptom; it is more commonly associated with opioid use. During withdrawal, pupils are likely to dilate rather than constrict.
- C) Euphoria is a feeling of intense happiness or excitement, which is often experienced after taking opioids. During withdrawal, individuals are more likely to experience dysphoria, which is a state of unease or dissatisfaction.
- D) Hypothermia is not a recognized symptom of opioid withdrawal. Instead, individuals may experience fever or chills as the body adjusts to the lack of opioids.
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