A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?
Administer an analgesic 30 min before starting the procedure.
Hold the syringe 5 cm (2 in) above the upper end of the wound.
Place the irrigation solution in a basin of cool water.
Perform the wound irrigation with a 10mL syringe with an angiocatheter.
The Correct Answer is A
A. Administer an analgesic 30 min before starting the procedure: Correct. Before performing wound irrigation, it is essential to provide pain relief to the client. Administering an analgesic 30 minutes before the procedure will help manage pain during wound irrigation.
B. Hold the syringe 5 cm (2 in) above the upper end of the wound: This action does not contribute to proper wound irrigation. The nurse should direct the irrigation solution to the wound site to cleanse it effectively.
C. Place the irrigation solution in a basin of cool water: Using cool water is not the best practice for wound irrigation. The irrigation solution should be at room temperature or a temperature specified by the healthcare provider.
D. Perform the wound irrigation with a 10mL syringe with an angiocatheter: Wound irrigation typically requires a larger volume of fluid to adequately cleanse the wound. A 10mL syringe may not be sufficient, and using an angiocatheter is not appropriate for wound irrigation. A larger syringe or irrigation solution bag with an appropriate wound irrigation tool is usually used.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Correct. Regular dental assessments every 6 months are recommended for all individuals, including young adults, to maintain good oral health and detect any potential issues early.
B: Incorrect. Testicular examinations are important for young adult males, but they should be performed monthly as part of testicular self-examination, not every 5 years.
C: Incorrect. Young adult females should have a routine physical examination annually, not every 4 years, to monitor their overall health and address any potential health concerns.
D: Incorrect. While tuberculosis screening is essential in certain populations, such as healthcare workers or individuals at high risk of exposure, a tuberculosis skin test every 3 years is not a standard recommendation for all young adults.
Correct Answer is B
Explanation
A. Empty the urine drainage bag every 12 hours: While it's essential to empty the urine drainage bag regularly to prevent it from becoming too full, emptying it every 12 hours alone is not sufficient to prevent urinary tract infections (UTIs).
B. Drain the urine from the tubing before ambulation: Correct. Before the client ambulates or moves, the nurse should ensure that the urinary catheter's tubing is emptied. This prevents urine from flowing back into the bladder, reducing the risk of UTIs.
C. Use clean technique for urine specimen collection: While using clean technique during urine specimen collection is important for preventing contamination, it is not the primary action needed to prevent UTIs in a client with an indwelling urinary catheter.
D. Hang the urine drainage bag at the level of the bladder: While proper positioning of the drainage bag is essential for optimal urine flow and to prevent backflow, it alone is not sufficient to prevent UTIs.
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