A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?

Use a 10-mL syringe filled with cleansing solution.

Dry the wound bed with gauze squares.

Cleanse the wound with cotton balls.

Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.

Answer and Explanation

The Correct Answer is A

A.   Using a 10-mL syringe filled with cleansing solution provides appropriate pressure for effective wound irrigation.
B.   Drying the wound bed with gauze squares is not typically recommended as it may disrupt healing and cause trauma to the wound.
C.   Cleansing the wound with cotton balls may leave fibers behind and is not the most effective method of wound irrigation.
D.   Holding the syringe tip 2.5 cm (1 in) above the wound is incorrect; the tip should be inserted into the wound to facilitate thorough irrigation.

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Correct Answer is C

Explanation

A. Wearing shoes with smooth soles may increase the risk of slipping and falling, especially for a client with mobility issues. It is not a safe recommendation.
B. Moving the cane forward 18 inches is too far and may lead to instability during ambulation.
Typically, the cane should be moved forward only about 6 to 12 inches.

C. Holding the cane on the stronger side provides better support and stability, as it allows the client to bear weight on the stronger side while using the cane for balance and support on the weaker side.
D. Moving the stronger leg forward before the weaker leg is a correct step in the gait pattern when using a cane or other assistive device for walking. However, the statement does not
specifically address the use of the quad cane.

A. Clammy skin B. Tortuous veins C. Bradycardia D. Calf swelling

Correct Answer is D

Explanation

A. Clammy skin may indicate various conditions, including shock or anxiety, but it is not

specifically indicative of deep-vein thrombosis. It is not the most concerning finding in this scenario.
B. Tortuous veins refer to veins that are twisted or enlarged, often visible on the surface of the skin. While tortuous veins may be present in some cases of deep-vein thrombosis, they are not a definitive sign and are less concerning than other symptoms.
C. Bradycardia, a slower than normal heart rate, is not typically associated with deep-vein

thrombosis. It may indicate other cardiovascular or systemic issues but is not the priority in this situation.
D. Calf swelling, especially unilateral swelling, is a common and concerning sign of deep-vein

thrombosis. It results from impaired venous return due to the presence of a blood clot in the deep veins of the leg. Prompt reporting of this finding is essential for further evaluation and
intervention.

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A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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