A nurse is preparing to irrigate a wound for a patient. What actions should the nurse plan to take?

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.

Rationale:

When administering multiple liquid medications through an NG tube, it’s important to administer each medication separately to prevent drug interactions. After each medication, the NG tube should be flushed with 30 mL of water to ensure that the medication has been fully administered and to prevent the tube from becoming clogged.