A nurse is preparing to assist with irrigating a wound for a client.
Which of the following actions should the nurse plan to take?

Irrigate the wound until the solution that is draining is clear.

Chill the irrigant prior to the procedure.

Hold the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating.

Flush the wound from the most contaminated area to the cleanest area.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.

Choice B rationale:

The irrigant should be at room temperature, not chilled.

Choice C rationale:

The syringe should be held 1 inch (not 0.5 inch) from the wound.

Choice D rationale:

The wound should be flushed from the cleanest area to the most contaminated, not the other way around.

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Correct Answer is A

Explanation

The correct answer is Choice A: Leave nonbleeding wounds open to air.

Choice A rationale:

During the initial stage of wound healing, also known as the inflammatory phase, it is important to keep nonbleeding wounds clean and dry, and exposed to air to promote healing and prevent infection.

Choice B rationale:

Administering a corticosteroid medication is not typically part of the initial wound care plan, as corticosteroids can suppress the immune response and delay healing.

Choice C rationale:

Mechanical debridement is used to remove dead tissue from a wound, but it is not usually part of the initial care plan unless there is a need to clean the wound of necrotic tissue.

Choice D rationale:

Applying oxygen at 2L/min via nasal cannula is not a standard part of initial wound care. Oxygen therapy is typically reserved for patients with specific respiratory conditions or severe hypoxemia.

A. Using a thermometer to check the temperature of the pad. B. Securing the pad to the patient. C. Assisting the patient to lie on top of the pad. D. Instructing the patient not to sleep on the pad. E. Inspecting the plug and cord for cracks or fraying.

Correct Answer is ["A","B","D","E"]

Explanation

E. Using a thermometer to check the temperature of the pad, Securing the pad to the patient, Instructing the patient not to sleep on the pad, Inspecting the plug and cord for cracks or fraying.

Choice A rationale:

It’s important to check the temperature of the pad to prevent burns.

Choice B rationale:

Securing the pad ensures it stays in place and provides consistent heat.

Choice C rationale:

Patients should not lie on top of the pad as it can lead to burns.

Choice D rationale:

Patients should not sleep on the pad to prevent prolonged exposure which can lead to burns.

Choice E rationale:

Inspecting the plug and cord prevents electrical hazards.

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A nurse is preparing to assist with irrigating a wound for a client.Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Correct Answer is A

Explanation

Safety factors involved in using an Aquathermia pad unit for a patient include (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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A nurse is preparing to assist with irrigating a wound for a client.
Which of the following actions should the nurse plan to take?