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

Cleanse the wound with cotton balls.

Use a 10-mL syringe filled with cleansing solution.

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

Dry the wound bed with gauze squares.

Answer and Explanation

The Correct Answer is C

A. Cleanse the wound with cotton balls – Cotton fibers can shed and leave debris in the wound, increasing the risk of infection. Gauze or irrigation is preferred.
B. Use a 10-mL syringe filled with cleansing solution – A 10-mL syringe does not provide sufficient pressure for effective irrigation. A 30- to 60-mL syringe is typically recommended.
C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound – This ensures appropriate pressure and prevents contamination while effectively flushing out debris.
D. Dry the wound bed with gauze squares – The wound bed should be kept moist to promote healing; only the surrounding skin should be dried if necessary.

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Correct Answer is C

Explanation

Rationale:

A. This response dismisses the concerns of the assistant personnel and is not supportive.

B. This response minimizes the assistant personnel's concerns and does not acknowledge their feelings.

C. This response acknowledges the assistant personnel's concerns and opens the door for further discussion.

D. This response does not address the assistant personnel's concerns and suggests a formal complaint as the only solution. It is not supportive or collaborative.

A. Make sure four fingers fit between the restraint and the client's body. B. Apply the belt restraint over the client's gown. C. Check the client's skin integrity every 4 hr. D. Tie the belt restraint to the side rail of the bed.

Correct Answer is B

Explanation

Rationale:

A. Ensuring that four fingers fit between the restraint and the client's body is important to prevent injury and discomfort.

B. Applying the belt restraint over the client's gown may lead to slippage and ineffective restraint.

C. Checking the client's skin integrity every 4 hours is important, but it is not specific to the use of a belt restraint.

D. Tying the belt restraint to the side rail of the bed is not appropriate because it can restrict movement and cause injury.

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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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Explanation

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Correct Answer is B

Explanation

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