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. The stoma bleeds lightly when touched: Light bleeding is common postoperatively and may not be concerning unless it's excessive or persistent.
B. The stoma is draining a small amount of liquid stool: This is a normal finding following colostomy placement and is expected in the early postoperative period.
C. The stoma appears dark in color: This may indicate compromised blood supply to the stoma and requires immediate evaluation by the provider.
D. The stoma protrudes slightly from the abdomen: This is a normal finding post-colostomy and does not typically require immediate intervention.

A. "How will you discuss this decision with your loved ones?" B. "Your quality of life will be compromised if you make this decision." C. "We should talk about your decision later." D. "Don't worry. Everything will work out for you."

Correct Answer is A

Explanation

A. This response acknowledges the client's decision and expresses concern for their well-being and the potential impact on their loved ones. It also opens the door for the client to discuss their decision-making process and receive support in communicating their decision to others.

B. This response may be perceived as judgmental or dismissive of the client's autonomy and decision-making capacity. It does not provide support or address the client's emotional or psychosocial needs.
C. Delaying the discussion may leave the client feeling unsupported or uncertain about their
decision. It's important to address the client's concerns and provide support in a timely manner.

D. This response minimizes the client's concerns and does not offer support or encouragement for discussing their decision with loved ones. It may also convey a lack of empathy or
understanding of the client's situation.

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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?

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