A nurse is preparing to irrigate a wound for a patient. What actions should the nurse plan to take?
Chill the irrigant prior to the procedure.
Irrigate the wound until the solution that is draining is clean.
Hold the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating.
Flush the wound from the most contaminated area to the cleanest area.
The Correct Answer is B
Choice A rationale
Chilling the irrigant prior to the procedure is not recommended. Cold irrigant can cause discomfort and potentially lead to vasoconstriction, which can impede the healing process.
Choice B rationale
Irrigating the wound until the solution that is draining is clean is a standard practice in wound care. This helps to ensure that all debris and potential contaminants are removed from the wound.
Choice C rationale
Holding the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating is not a standard practice. The syringe should be held close to the wound to ensure effective irrigation.
Choice D rationale
Flushing the wound from the most contaminated area to the cleanest area is not a standard practice. The wound should be irrigated from the cleanest to the dirtiest area to prevent the spread of contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
Step 1 is to understand the question. The patient has been prescribed vancomycin 1 g in 250 mL dextrose 5% (D5W) to be administered over 2 hours via IV intermittent bolus. We need to calculate how many mL/hr the nurse should set the IV pump to deliver.
Step 2 is to calculate the rate. The total volume to be administered is 250 mL and the time for administration is 2 hours. So, the rate is 250 mL ÷ 2 hours = 125 mL/hr.
Correct Answer is D
Explanation
Choice A rationale
Glaucoma is a condition that damages the eye’s optic nerve and can result in vision loss and blindness. However, it doesn’t cause a cloudy, opaque area over the lens of the eye.
Choice B rationale
Diabetic retinopathy is a diabetes complication that affects eyes. It’s caused by damage to the blood vessels of the light-sensitive tissue at the back of the eye (retina). But it doesn’t cause a cloudy, opaque area over the lens of the eye.
Choice C rationale
Macular degeneration is a medical condition which may result in blurred or no vision in the center of the visual field. But it doesn’t cause a cloudy, opaque area over the lens of the eye.
Choice D rationale
A cataract is a clouding of the lens in the eye that affects vision. Cataracts are very common in older people. Symptoms of cataracts include cloudy or blurry vision.
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