A nurse is preparing to irrigate a wound for a client.
Which of the following actions should the nurse plan to take?
Hold the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating.
Chill the irrigant prior to the procedure.
Flush the wound from the most contaminated area to the cleanest area.
Irrigate the wound until the solution that is draining is clear.
The Correct Answer is D
Choice A rationale:
Holding the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating is not the best practice for wound irrigation. It's crucial to maintain a close distance to the wound to ensure that the irrigation solution effectively cleans the area.
Choice B rationale:
Chilling the irrigant prior to the procedure is not necessary and could be uncomfortable for the patient. Room temperature or slightly warmed sterile saline solution is typically used for wound irrigation to prevent temperature-related discomfort.
Choice C rationale:
Flushing the wound from the most contaminated area to the cleanest area is an incorrect approach for wound irrigation. The wound should be irrigated from the cleanest to the most contaminated to prevent contamination of previously clean areas and ensures thorough cleaning of the wound.
Choice D rationale:
Irrigating the wound until the solution that is draining is clear is a common practice for wound irrigation. It indicates that the wound is free of contaminants, debris, and infectious material.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The "Region" in the PQRST mnemonic refers to the location of the pain. It helps identify where the pain is occurring in the body. While this information is important, it does not address the quality or nature of the pain, which is what the nurse is asking the client to describe.
Choice B rationale:
"Severity" in the PQRST mnemonic relates to how intense the pain is. It helps in assessing the degree of pain the client is experiencing, but it does not address the quality or nature of the pain, which is what the nurse is inquiring about.
Choice C rationale:
"Quality" in the PQRST mnemonic pertains to the description of the pain itself. It helps the nurse understand the characteristics of the pain, such as whether it is sharp, dull, burning, throbbing, etc. This information is essential for a more accurate assessment of the pain's underlying cause, making it the correct choice in this scenario.
Choice D rationale:
"Precipitating cause" in the PQRST mnemonic is concerned with what factors or actions might trigger the pain. While this information is valuable, it does not directly address the nature or quality of the pain, which is what the nurse is trying to assess.
Correct Answer is A
Explanation
Choice A rationale:
Administering IV medication via an oral route is a medication error and should be reported.
Choice B rationale:
A client vomiting their morning medications is an adverse event, but not all adverse events require an incident report. The nurse should assess the situation and report if it poses a risk to the patient's health.
Choice C rationale:
Administering a lipid-lowering medication to a client one hour after the scheduled time is a medication error, but again, the need for an incident report depends on the potential harm to the patient. In some cases, reporting this incident may be necessary.
Choice D rationale
An allergic reaction can occur in clients with no known drug allergies. Unless a drug was given in known allergies, it does not require an incident report.
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