The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included?
a. Allowing the solution to flow from the most contaminated to the least contaminated
b. Scrubbing vigorously when applying solutions to the skin
c. Cleansing in a direction from the least contaminated area
d. Utilizing clean gauge and clean gloves to cleanse a site
ANS: C
Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.
You might also like to view...
Order: Lasix 20 mg IVP Available: Lasix 40 mg/4 mL
a. 1 mL b. 3 mL c. 2 mL d. 1.5 mL
A client who has been diagnosed with a benign tumor asks the nurse how long it will be until the tumor begins to spread. The nurse should teach the client that:
1. malignant tumors are slow-growing. 2. benign tumors are encapsulated and local. 3. benign tumors spread through the lymphatic system. 4. malignant tumors are not invasive.
When a pregnant woman with phenylketonuria (PKU) has a poorly regulated phenylalanine level, it causes an increase in the incidence of which condition in the fetus or neonate?
a. pulmonary defects b. intrauterine growth retardation (IUGR) c. hydrocephalus d. PKU
The nurse is performing a physical examination of an 8-year-old girl who was bitten by her kitten. Which of the following assessments would lead the nurse to suspect cat-scratch disease?
A) Swollen lymph nodes B) Strawberry tongue C) Infected tonsils D) Swollen neck