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 A
Explanation
Choice A rationale
A purplish-colored stoma may indicate compromised circulation, which is a serious condition that requires immediate medical attention18.
Choice B rationale
A rosebud-like stoma orifice is a normal finding and does not need to be reported18.
Choice C rationale
A stoma oozing red drainage is a normal finding immediately after surgery and does not need to be reported18.
Choice D rationale
A shiny, moist stoma is a normal finding and does not need to be reported18.
Correct Answer is A
Explanation
Choice A rationale
The nurse should plan to refrigerate the urine during the collection time period. This is because the urine needs to be kept cool to prevent the breakdown of certain analytes that might be measured in the urine.
Choice B rationale
The nurse should not discard the client’s last void at the end of the collection time period. The last voided specimen should be included in the collection to ensure that the 24-hour collection is complete.
Choice C rationale
The nurse should not include toilet paper with the collected urine. Toilet paper could contaminate the urine sample and interfere with the accuracy of the test results.
Choice D rationale
The nurse should not save the first void at the start of the collection time period. The first voided specimen should be discarded, and the collection should start with the next void.
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