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 A
Explanation
Choice A rationale:
Kohlberg's theory of moral development includes several stages, and in the stage of the social contract, individuals begin to challenge rules and laws that they believe infringe upon the rights of others. This stage is characterized by the development of a sense of justice and social responsibility. Individuals in this stage may question laws and rules that they see as unjust and work towards changing them in favor of the greater good.
Choice B rationale:
Law and order is a stage in Kohlberg's theory where individuals prioritize following the established laws and rules of society. They may not necessarily challenge these rules, as their primary concern is maintaining order and obedience to authority.
Choice C rationale:
Punishment and obedience is one of the earlier stages in Kohlberg's theory, where individuals focus on avoiding punishment and obeying authority figures. This stage does not involve challenging rules for the sake of protecting the rights of others.
Choice D rationale:
Good boy-nice girl is a stage where individuals seek approval and avoid disapproval from others. They tend to conform to societal expectations and do not necessarily challenge rules that may impinge on the rights of others.
Correct Answer is A
Explanation
Choice A rationale:
Establishing whether the client's grieving is healthy or complicated is the first step in the nursing process when caring for a client experiencing grief. This step falls under the assessment phase of the nursing process and is essential for understanding the client's needs and planning appropriate care.
Choice B rationale:
Developing client-specific goals and outcomes comes after the assessment phase in the planning stage of the nursing process. While important, it is not the first action the nurse should take in this situation.
Choice C rationale:
Incorporating the treatment into the client's care occurs during the implementation phase of the nursing process and follows assessment and planning. This is not the first action.
Choice D rationale:
Determining whether coping strategies were successful is part of the evaluation phase of the nursing process, which occurs after the implementation of care. It is not the first step in this situation. Now, let's proceed to the final question.
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