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 A
Explanation
The correct answer is choice A. Use warm water when bathing the client.
Choice A rationale:
Using warm water when bathing helps maintain skin integrity by ensuring the skin is clean without causing excessive dryness or irritation. Warm water is gentle on the skin and helps in maintaining its natural moisture balance.
Choice B rationale:
Placing a donut-shaped cushion in the client’s chair is not recommended as it can cause pressure points and restrict blood flow, potentially leading to pressure ulcers.
Choice C rationale:
Massaging reddened areas over bony prominences is not advisable because it can cause further damage to already compromised skin and increase the risk of pressure ulcers.
Choice D rationale:
Maintaining the client in high-Fowler’s position for extended periods can increase pressure on the sacral area, leading to pressure ulcers. It is important to regularly reposition the client to alleviate pressure.
Correct Answer is D
Explanation
The correct answer is choice d. Notify the charge nurse of the client’s concerns.
Choice A rationale:
Offering information about alternative therapies is not appropriate in this situation. The nurse’s role is to ensure the client understands the current procedure and to address their concerns, not to suggest alternatives unless directed by the healthcare provider.
Choice B rationale:
Contacting a family member to convince the client to change their mind is not ethical. The decision to proceed with surgery should be made by the client, based on their understanding and consent, not under pressure from family members.
Choice C rationale:
Telling the client the benefits of the surgery might be helpful, but it does not address the client’s lack of understanding about the procedure. The nurse should ensure the client has all the necessary information to make an informed decision.
Choice D rationale:
Notifying the charge nurse of the client’s concerns is the correct action. The charge nurse can facilitate further discussion with the surgeon to ensure the client receives the necessary information and support to make an informed decision. This ensures that the client’s autonomy and right to informed consent are respected.
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