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 B

Explanation

A. Limiting snacks between meals may further decrease the client's overall food intake, which could exacerbate the risk of malnutrition.

B. Providing the client with finger foods makes eating more manageable for individuals with dementia who may have difficulty using utensils or maintaining attention during meals. This approach encourages independent eating and may increase food intake.
C. Restricting visitors during meals may lead to social isolation and could interfere with the client's enjoyment of mealtime, potentially further reducing food intake.
D. Providing the client with three large meals each day may be overwhelming and may not align with the client's preferences or eating habits. Offering smaller, more frequent meals throughout
the day is often more manageable for individuals with dementia.

A. "I should wear shoes with smooth soles to help slide my weak leg forward." B. "I will move the cane forward 18 inches." C. "I will hold the cane on my stronger side." D. "I should move my stronger leg forward before moving my weaker leg."

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.

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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

A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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