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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

An increase in skin thinning is not a typical age-related change in the skin. In older adults, skin tends to become thinner due to a decrease in subcutaneous tissue, making it more fragile and susceptible to damage.

Choice B rationale:

An increase in skin elasticity is not a common characteristic of aging skin. In fact, older adults often experience a decrease in skin elasticity, leading to wrinkles and sagging skin.

Choice D rationale:

While there may be changes in blood supply to the skin as people age, an increase in blood supply is not a well-established or typical age-related change. Decreased blood flow to the skin is more common in older adults.

Choice E rationale:

Decrease in skin hydration is a common age-related change, but it's not the most significant change mentioned in the question. The primary focus in older adults is the decrease in subcutaneous tissue, which has a more direct impact on skin health.

A. Discard the client's last void at the end of the collection time period. B. Include toilet paper with the collected urine. C. Save the first void at the start of the collection time period. D. Refrigerate the urine during the collection time period.

Correct Answer is D

Explanation

Choice A rationale:

Discard the client's last void at the end of the collection time period. This choice is not appropriate. When conducting a 24-hour urine collection, it's essential to include all urine produced during the specified time frame. Discarding the last void would result in an incomplete and inaccurate collection.

Choice B rationale:

Include toilet paper with the collected urine. This choice is also incorrect. Toilet paper is not typically included in a 24-hour urine collection. The purpose of this collection is to accurately measure substances excreted by the kidneys over a specific time period. Toilet paper is not part of this measurement and should not be included.

Choice D rationale:

This helps prevent the breakdown of certain substances and ensures the sample's accuracy. Failure to refrigerate the urine can lead to inaccurate test results. Now, let's discuss the rationale for the correct answer, choice C:

Choice C rationale:

The first void at the beginning of the collection period is typically discarded, as it represents the urine that was in the bladder before the timed collection started. This helps ensure that the collection is accurate and only includes urine produced during the specified 24-hour period. It's important to follow this protocol to obtain reliable test results.

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A nurse is preparing to irrigate a wound for a client. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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A nurse is preparing to irrigate a wound for a client.
Which of the following actions should the nurse plan to take?