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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. A BMI of 30 or higher is classified as obese.
B. A BMI between 25 and 29.9 is classified as overweight.
C. A BMI below 18.5 is classified as underweight.
D. A BMI between 18.5 and 24.9 is classified as ideal body weight.
Correct Answer is ["A","B","C","D"]
Explanation
A. The client has hypertension and high sodium levels, indicating fluid retention, so a diuretic may be prescribed to help manage these conditions.
B. The client reports difficulty sleeping without drinking several beers a night, indicating a potential alcohol problem. Limiting alcohol intake is a common recommendation for clients with this issue.
C. The client has elevated LDL cholesterol, indicating high-fat intake, so limiting fat intake can help manage this.
D. The client has elevated sodium levels, so reducing sodium intake can help manage this.
E. There is no indication for an antibiotic prescription based on the client's symptoms and lab results.
F. There is no indication of high potassium levels, so limiting foods high in potassium is not necessary.
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