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 B
Explanation
Choice A rationale:
Increased sensitivity to touch is not typically an age-related change in older adults. In fact, older adults often experience a decrease in sensitivity due to factors like reduced skin elasticity and changes in nerve function.
Choice C rationale:
Increased peripheral vision is not a common age-related change. Visual changes in older adults usually involve decreased visual acuity, difficulties with night vision, and increased sensitivity to glare.
Choice D rationale:
An increase in the size of pupils is not an expected age-related change. Pupils may become smaller and react more sluggishly to changes in light in older adults, but a consistent increase in pupil size is not a common finding.
Choice B rationale:
An increase in cerumen in the ear canal is a common age-related change. Cerumen, or earwax, can accumulate more in older adults due to changes in the composition of earwax and slower migration of earwax out of the ear canal. It can lead to hearing difficulties and may need management. Moving on to the last question.
Correct Answer is
Explanation
Choice A rationale:
Constipation in a client on bedrest is a common issue, and one of the primary interventions is to increase fluid intake. Adequate hydration helps soften the stool, making it easier to pass, and can prevent constipation. This intervention is based on sound nursing principles and is the most appropriate choice.
Choice B rationale:
Encouraging the client to drink cold fluids is not a specific intervention for constipation. While staying hydrated is important, the temperature of the fluids is not as relevant to relieving constipation as the overall fluid intake.
Choice C rationale:
Requesting a prescription for mineral oil is not the first-line intervention for constipation. Mineral oil can have potential side effects and should only be used when other measures have failed. Increasing fluid intake and dietary fiber are typically the initial steps taken.
Choice D rationale:
Placing the client on a low-fiber diet is not an appropriate intervention for constipation. A low-fiber diet can exacerbate constipation by reducing the bulk and softness of the stool. This choice is counterproductive to addressing the issue.
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