Irrigating Wounds
Which device is used for wound irrigation? A. 19-gauge needle attached to a 10-mL syringe B. 19-gauge needle attached to a 35-mL syringe C. Sterile container held 30.5 cm (12 inches) above the wound D. Foley irrigating syringe
19-gauge needle attached to a 35-mL syringe Rationale: A 19-gauge needle attached to a 35-mL syringe will release a sufficient quantity of solution at the correct pressure for wound irrigation. A 19-gauge needle attached to a 10-mL syringe will not supply enough solution for wound irrigation, nor will it release it at the recommended pressure. Holding a container of solution above the wound would yield an unpredictable result and would probably be ineffective for wound irrigation. A Foley irrigating syringe will not release a sufficient quantity of solution at the right pressure for wound irrigation.
Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient's left heel is infected? A. White blood cell count B. Complete blood count C. X-ray of left foot D. Culture and sensitivity test
Culture and sensitivity test Rationale: A wound culture and sensitivity test will indicate whether the pressure ulcer is infected, identify the pathogen responsible (if any), and determine which antibiotic the pathogen is most vulnerable to. Although an elevated white blood cell count indicates infection, it would not be specific to the pressure ulcer in question. The complete blood count cannot indicate or rule out infection. The nurse would not consult an imaging study to determine whether the patient's pressure ulcer is infected.
A nurse is irrigating a patient's abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider? A. Drainage that was not present previously B. Redness at the abdominal suture line C. Granulation tissue in the wound bed D. The patient reports less pain
Drainage that was not present previously Rationale: The appearance of new drainage indicates possible wound infection. Redness at the incision site does not necessarily indicate a postsurgical complication. The appearance of granulation tissue indicates wound healing. Pain is expected during wound care at this time.
When irrigating a wound, how would the nurse know the right amount of pressure to apply? A. Calculate the wound size. B. Follow the general rule of keeping the pressure between 4 and 15 psi. C. Keep the pressure strong enough to cause moderate pain. D. Gentle enough that is does not create a splash off of the wound.
Follow the general rule of keeping the pressure between 4 and 15 psi. Rationale: Less than 4 psi would not be effective. More than 15 psi is likely to cause tissue damage. The amount of irrigant, not the pressure, is dictated by the wound size. Irrigation will cause different amounts of pain with different patients. This is not a good gauge by which to determine the correct amount of pressure to apply. The amount of pressure is gauged with PSI, not with splash off the wound.
Which action should the nurse avoid before irrigating a patient's foot wound? A. Assess the patient for a history of allergies to tape and irrigating solution. B. Review the provider's orders for the type of irrigating solution to be used. C. Assess the patient's pain on a scale of 0 to 10. D. Warm the irrigant to body temperature in the microwave.
Warm the irrigant to body temperature in the microwave. Rationale: Although the nurse must warm the solution before irrigating the wound, using the microwave can create hotspots and make the fluid unsafe. The nurse would assess the patient's allergy history before beginning the irrigation. The nurse must review the provider's order before initiating the intervention in order to select the correct irrigating solution. It is appropriate to assess the patient's pain before initiating the intervention.