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 stoma that protrudes slightly from the abdomen is normal after colostomy surgery.
B. A stoma that appears dark in color may indicate compromised blood flow and should be reported to the provider.
C. A stoma that bleeds lightly when touched is normal after colostomy surgery.
D. A stoma that is draining a small amount of liquid stool is normal after colostomy surgery.
Correct Answer is A
Explanation
Rationale:
A. Regular clinical breast examinations by a healthcare provider are recommended for all women, typically starting at age 30, regardless of family history, as part of early detection efforts for breast cancer.
B. While mammograms are important for breast cancer screening, the age at which they should start may vary based on individual risk factors and guidelines from different organizations.
C. Breast ultrasound may be used in specific cases but is not typically recommended as a routine screening tool for breast cancer in asymptomatic women without specific risk factors.
D. Breast self-examinations are important for women to become familiar with their breasts and detect any changes, but the age at which they should start may vary based on individual risk factors and guidelines.
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