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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Eating apples and black-eyed peas is not typically associated with impaired bowel
elimination. In fact, these foods are often considered high in fiber, which can promote regular bowel movements.
B. Drinking an adequate amount of water daily is generally beneficial for bowel health and can help prevent constipation.
C. Taking opioid pain medication is a significant risk factor for impaired bowel elimination.
Opioids are known to slow down bowel motility and can lead to constipation.
D. Drinking coffee in moderation may have a mild laxative effect for some individuals and is not necessarily indicative of impaired bowel elimination.
Correct Answer is ["A","B","C","D","E"]
Explanation
In the scenario provided, the nurse should take further action based on the following findings: The client's distended abdomen, reports of nausea, and coughing suggest possible intolerance to the tube feedings or another complication. A gastric residual volume of 550 mL is significantly higher than the standard safe limit of 500 mL, indicating delayed gastric emptying or feeding intolerance. The pH of gastric aspirate at 4.5 is within normal limits, suggesting that the tube is likely placed correctly. However, the elevated heart rate of 110/min could be a response to discomfort or underlying stress. The pulse oximetry reading of 90% on room air is below the normal range, which typically is 95-100%, indicating potential impaired gas exchange or early signs of respiratory distress. These findings warrant immediate nursing interventions and possibly a reassessment of the feeding regimen, along with measures to improve the client's respiratory function and comfort. It is essential to monitor for further signs of aspiration, respiratory distress, or other complications, and to communicate these findings to the healthcare team for appropriate management.
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