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Perform wound cleansing and irrigation - 🧠ANSWER ✔✔1. For clean
wounds (a surgical incision),cleanse from the least contaminate (the
incision) toward the most contaminated (the surrounding skin).
2. Use gentle friction when cleansing or applying solutions the skin to avoid
bleeding or further injury to the wound.
What cleansing agents should you use when performing for wound
irrigation? - 🧠ANSWER ✔✔1. Provider might prescribe mild cleansing
agents
2. Isotonic solutions remain the preferred cleansing agents
How should you use the gauze for cleansing a wound and irrigating a
wound? - 🧠ANSWER ✔✔1. Never use the same gauze to cleanse across
an incision of wound more than once.
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,2. Do not use cotton balls and other products that shed fibe
What should you use when irrigating the wound and cleaning the wound? -
🧠ANSWER ✔✔1. If irrigating - use a piston syringe or a sterile straight
catheter for deep wounds with small openings.
2. Apply 5 to 8 psi of pressure.
3. A 30 to 60 mL syringe with a 19- gause needle provide approximately 8
psi.
4. Use normal saline, lactated rangers or an antibiotic/ antimicrobial
solution.
How high should you hold it above the wound for irrigating the wound? -
🧠ANSWER ✔✔1. Hold the tip 2.5 cm (1 in) above the wound.
2.Use continuous pressure to flush the wound, repeating the procedure
until the irrigant flowing out of the wound is clear.
Do you remove the sutures when irrigating a wound? - 🧠ANSWER ✔✔1.
Remove sutures and staples
What medication do you administer for irrigating a wound? - 🧠ANSWER
✔✔1. Admin analgesics and monitor for effective pain management.
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,2. Admin antimicrobials (topical, systemic) and monitor for effectiveness
(reduced fever, increase in comfort, decreasing WBC count ).
A nurse is caring for a client who is 2 days postoperative following an
appendectomy and has type 1 DM. Their Hgb is 12 g/dL and BMI is 17.1.
The incision is approximated and free of redness, with scant serous
drainage on the dressing. The nurse should recognize that the patient has
which of the following risk factors for impaired wound healing? -
🧠ANSWER ✔✔B. Chronic Illness ------------DM is a chronic illness that
place
additional stress on the body healing mechanisms.
C.Low Hemoglobin----------Hgb is essential for oxygen delivery to healing
tissues and the patients HGB level is low.
D. Malnutrition- A BMI of 17.1 indicates that the patient is underweight and
therefore malnourished. Deficiencies in essential nutrients delay wound
healing.
A nurse is collecting data from a client who is 5 days postoperative
following abdominal surgery. The surgeon suspects and incisional wound
infection and has prescribed antibiotic therapy for the nurse to initiate after
collecting wound and blood specimens for culture and sensitivity. Which of
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, the following findings should the nurse expect? - 🧠ANSWER ✔✔A.Increase
in incisional pain
B. Fever and chills
C. Reddened wound edges
A nurse educator is reviewing the wound healing process with a group of
nurses. The nurse educator should includ in the information which of the
following alteration for wound healing by secondary intention? - 🧠ANSWER
✔✔A.Stage 3 pressure injury-----Open pressure ulcers heal by secondary
intention which is the process for wound that have tissue loss and widely
separated edges.
E.Open burn area------Open burn areas heal by secondary intention which
is the process for wounds that have tissue loss and widely separated
edges.
A patient who had abdominal surgery 24 hour ago suddenly reports a
pulling sensation and pain in their surgical incision. The nurses checks the
surgical wound and finds it separated with viscera protruding (abdominal
cavities in the body). Which of the following actions should the nurse take?
- 🧠ANSWER ✔✔A. Cover the area with saline- soaked dressing. sterile
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