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
A. Cleaning around the stoma with a moisturizing soap is not recommended. Moisturizing soaps can leave a residue that may interfere with the adhesion of the skin barrier. The client should use warm water or a mild, non-moisturizing soap to clean the area.
B. Pressing on the skin barrier for 30 seconds to ensure that it adheres is correct. This technique helps secure the barrier to the skin, creating a good seal and reducing the risk of leaks.
C. Cutting an opening in the skin barrier that is 1/2 inch larger than the stoma is incorrect. The opening should be about 1/8 inch larger than the stoma to ensure a snug fit, which helps protect the surrounding skin from exposure to effluent.
D. Applying a thin layer of talc powder around the stoma before placing the appliance is not appropriate. Powders are typically used to manage irritated skin but should be avoided unless specifically recommended by a healthcare provider. Overuse can interfere with the appliance’s adhesion.
Correct Answer is C,A,B,D,E
Explanation
A. Opening the outside cover of the sterile kit and removing the dust cover exposes the sterile supplies within the kit.
B. Grasping the outermost flap of the sterile kit while opening away from the body helps maintain the sterility of the contents within the kit.
C. Preparing a dry work surface above the waist level ensures that the sterile field is established at a proper height and that the nurse's hands are at the appropriate level for working within the sterile field.
D. Opening the innermost lower flap of the sterile kit while standing away from the sterile field allows the nurse to access the sterile supplies without contaminating the sterile field.
E. Opening each side flap of the sterile kit individually while pulling to the side further establishes the sterile field and provides access to the sterile supplies.
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