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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale:

Count the client's radial and apical pulses simultaneously with another nurse. Rationale: In the presence of an irregular heart rate, a pulse deficit might indicate a discrepancy between the peripheral (radial) and central (apical) pulses. Counting the pulses simultaneously with another nurse helps to accurately assess this deficit. By comparing the two pulse rates, the nurse can identify if there is a difference, which might indicate inadequate circulation or irregular heartbeats that aren't effectively transmitting to the peripheral arteries.

Choice B rationale:

Calculate the client's pulse for 30 seconds and multiply by 2. Rationale: While calculating the pulse rate for 30 seconds and then multiplying by 2 is a valid method to determine the heart rate, it doesn't address the specific concern of a pulse deficit. This approach might help in assessing the overall heart rate but doesn't provide information about potential irregularities or discrepancies between peripheral and central pulses.

Choice C rationale:

Assist the client to a side-lying position. Rationale: Assisting the client to a side-lying position doesn't directly relate to the assessment of a pulse deficit. The position of the client wouldn't significantly impact the assessment of irregular heart rates or pulse deficits.

Choice D rationale:

Auscultate the area of the client's chest over the Erb's point. Rationale: Auscultating the area of the client's chest over the Erb's point is a technique used to assess heart sounds, particularly the S2 heart sound. This technique is not relevant to assessing a pulse deficit. It can provide information about heart valve function but doesn't help in evaluating a discrepancy between peripheral and central pulses.

A. Perform a bladder scan. B. Cleanse the meatus. C. Provide perineal care. D. Lubricate the catheter.

Correct Answer is A

Explanation

The correct answer is choice A. Perform a bladder scan.

Choice A rationale:

Performing a bladder scan is the first action the nurse should take before proceeding with intermittent urinary catheterization. A bladder scan assesses the bladder's volume and determines if catheterization is necessary. It helps avoid unnecessary catheterizations, reduces the risk of infection, and promotes patient comfort.

Choice B rationale:

While cleansing the meatus and providing perineal care are important steps in preparing for urinary catheterization, they come after assessing the need for catheterization. Without knowing the bladder volume, these actions could be premature.

Choice C rationale:

Providing perineal care is important for maintaining hygiene and preventing infection, but it should be done after the decision for catheterization has been made based on the bladder scan results.

Choice D rationale:

Lubricating the catheter is a step that should be taken after the decision for catheterization is made and the need for catheterization is confirmed. It helps ease the insertion process and reduce discomfort for the patient.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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