Author Question: The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention ... (Read 26 times)

nummyann · **on:** Jul 22, 2018

The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included?

a. Allow the solution to flow from the most contaminated to the least contaminated.
b. Scrub vigorously when applying noncytotoxic solution to the skin.
c. Cleanse in a direction from the least contaminated area.
d. Utilize clean gauze and clean gloves to cleanse a site.

Question 2

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient?

a. Place the patient in a 30-degree supine position.
b. Utilize a transfer device to lift the patient.
c. Elevate the head of the bed 45 degrees.
d. Slide the patient into the new position.

CharlieArnold · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: C
Cleanse in a direction from the least contaminated area, such as from the wound or incision, to the surrounding skin. While cleansing surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or by irrigations is correct, vigorous scrubbing is inappropriate and can cause damage to the skin. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.

Answer to Question 2

ANS: B
When repositioning the patient, obtain assistance and utilize a transfer device to lift rather than drag the patient. Sliding the patient into the new position will increase friction. The patient should be placed in a 30-degree lateral position, not a supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.