A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use?
A piston syringe.
Barrier ointment.
Chilled irrigation solution.
Sterile cotton balls.
The Correct Answer is A
Choice A rationale:
The correct answer. A piston syringe is used for wound irrigation to deliver a controlled and directed flow of fluid to clean the wound. It helps remove debris and promote healing. This choice aligns with wound irrigation best practices.
Choice B rationale:
Barrier ointment is not typically used for wound irrigation. Its purpose is to protect intact skin from moisture, friction, and other irritants, rather than to clean wounds.
Choice C rationale:
Chilled irrigation solution is not commonly used for wound irrigation. Room temperature or warm sterile saline is usually recommended for wound cleansing as cold solutions can cause discomfort and vasoconstriction.
Choice D rationale:
Sterile cotton balls are not used for wound irrigation. They may leave fibers in the wound, potentially leading to infection. Wound irrigation is usually performed using sterile syringes, solutions, and appropriate irrigation devices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Performance of a paracentesis.
Choice A rationale:
Administration of an enema does not require informed consent in the same way that invasive procedures do. Enemas are typically considered routine nursing interventions and are not as invasive as the other options.
Choice B rationale:
This is the correct choice. A paracentesis is an invasive procedure that involves puncturing the abdominal cavity to withdraw fluid. Informed consent is required for procedures that carry potential risks, and paracentesis falls into this category due to the risk of complications such as infection, bleeding, or organ injury.
Choice C rationale:
Insertion of an indwelling urinary catheter is a common nursing procedure that, while invasive, does not typically require informed consent. However, the nurse should still explain the procedure to the client and obtain verbal consent, but it's not the same level of formal informed consent required for more invasive procedures.
Choice D rationale:
Placement of an NG tube, although uncomfortable, is not as invasive as a paracentesis. In most cases, NG tube placement is considered a medical or nursing intervention rather than a procedure that necessitates formal informed consent.
Correct Answer is B
Explanation
The correct answer is choice B: "Please don't tell my doctor, but I am taking my partner's oxycodone."
Choice B rationale:
This statement presents an ethical dilemma as it reveals the client's engagement in potentially harmful and illegal behavior – taking a controlled substance prescribed for someone else. The nurse must balance the duty to respect the client's confidentiality with the responsibility to address potential harm to the client and others involved.
Choice A rationale:
"I might file a lawsuit because of how my surgery went" does not present an ethical dilemma, but rather a legal concern. While the nurse should listen to the client's complaints and provide appropriate support, this statement is more related to the client's dissatisfaction with their medical care.
Choice C rationale:
"Please don't get me out of bed this morning, It hurts too much" reflects a client's pain management request. While pain management is important, this statement doesn't raise an ethical dilemma on its own. It's within the scope of care to address pain and comfort concerns.
Choice D rationale:
"I don't want to take my medicine. It makes me sick to my stomach" highlights a client's concern about medication side effects. While addressing medication concerns is essential, this statement doesn't inherently pose an ethical dilemma.
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