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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "This can help prevent nausea." Turning, coughing, and deep breathing exercises are not primarily aimed at preventing nausea. These exercises are designed to maintain lung function and prevent respiratory complications.
B. "This can help prevent pneumonia." Correct. Turning, coughing, and deep breathing exercises are essential postoperative activities that help prevent the development of pneumonia by promoting lung expansion, clearing mucus, and preventing atelectasis.
C. "I should do this every 4 hours." The frequency of turning, coughing, and deep breathing exercises may vary based on individual client needs and surgical procedures. This statement does not demonstrate a specific understanding of the appropriate timing for these exercises.
D. "I should do this to keep my heart from beating too fast." Turning, coughing, and deep breathing exercises are not directly related to heart rate regulation. They are focused on lung expansion and airway clearance.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}

Explanation

Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and an increase in heart rate from 88 to 100.

Itching: itching is an immediate symptom of type 1 hypersensitivity reactions that are common with blood transfusion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}

Explanation

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