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 D
Explanation
A. "Keep your knees in a locked position when standing for prolonged periods." This instruction is incorrect. Keeping knees locked can lead to muscle fatigue and increased risk of injury during prolonged standing.
B. "Bend at the waist when lifting a heavy object." This instruction is incorrect. Bending at the waist during lifting can strain the lower back and increase the risk of back injuries.
C. "Keep your feet close together when lifting a heavy object." This instruction is incorrect.
Keeping feet close together can make the base unstable and increase the risk of falling or losing balance during lifting.
D. "When lifting a heavy object, keep it close to your body." Correct. Keeping the heavy object close to the body while lifting helps reduce strain on the back and minimizes the risk of injury. This technique allows the body's core muscles to better support the weight.
Correct Answer is C
Explanation
A: Allowing the client to continue taking medications as they did at home without verifying the prescriptions can be unsafe and is not within the scope of nursing practice.
B: Taking the medications from the client and discarding them is inappropriate. The nurse should not dispose of the client's medications without proper assessment and verification.
C: Correct. The nurse should compare the medications the provider has prescribed with the medications the client brought from home to ensure accuracy and safety. This is a crucial step during admission to prevent errors or omissions in the medication regimen.
D: Placing the medications in the medication cart and administering them without verification is unsafe and against best practices for medication administration.
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