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 B
Explanation
Choice A rationale
Troponin is a cardiac enzyme which indicates a client has experienced a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.
Choice B rationale
Albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time. Therefore, a nurse
should expect altered albumin levels in a client who reports anorexia and is experiencing malnutrition.
Choice C rationale
Total bilirubin is altered in clients who are experiencing hepatobiliary disease. It is not a laboratory test that supports a diagnosis of malnutrition.
Choice D rationale
Creatine kinase is a cardiac enzyme which is useful in the diagnosis of a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.
Correct Answer is ["A","C"]
Explanation
Choice A rationale
A specific gravity of 1.036 is higher than the normal range of 1.005 to 1.030345. This could indicate dehydration or other conditions that cause the urine to be more concentrated. This finding should prompt the nurse to follow up.
Choice B rationale
A pH of 6.4 is within the normal range for urine, which is typically between 4.6 and 8.03. Therefore, this finding would not necessarily require follow-up.
Choice C rationale
The presence of proteinuria (protein in the urine) is abnormal and could indicate kidney disease or other serious health conditions. This finding should prompt the nurse to follow up.
Choice D rationale
The presence of hematuria (blood in the urine) can be a sign of several conditions, including urinary tract infections, kidney stones, or bladder infections. However, without more information, it’s not clear whether this finding alone should prompt the nurse to follow up.
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