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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Repositioning the patient for bed changing does not directly contribute to skin breakdown or infection.

Choice B rationale:

While shearing can cause skin breakdown, it is not directly related to incontinence or wet sheets.

Choice C rationale:

Moisture from incontinence can create an environment suitable for the growth of microorganisms in a wound, leading to infection and skin breakdown.

Choice D rationale:

A wet bed does not exert greater pressure on the patient’s skin.

A. Ask someone to quickly get an abdominal binder. B. Assist the patient in a supine position. C. Seat the patient in a nearby chair. D. Instruct the patient to pant to reduce abdominal tension.

Correct Answer is B

Explanation

Choice A rationale:

Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.

Choice B rationale:

Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.

Choice C rationale:

Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

Choice D rationale:

Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is incontinent the first day after his surgery.This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:

Correct Answer is C

Explanation

A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

Correct Answer is B

Explanation

The nurse places Dakin solution in a wound to accomplish chemical:

A patient has a pooling of blood under unbroken skin of the hip after a fall.The nurse should document that this patient has a(n):

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a:

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

A nurse performing a right eye irrigation will position the patient:

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?

A nurse is caring for a client who has heavy drainage from a moist red wound that is bleeding.Which of the following types of dressings should the nurse select to help promote hemostasis?

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