Nokea
A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?
- A. Apply oxygen at 2 L/min via nasal cannula.
- B. Initiate mechanical debridement.
- C. Leave non-bleeding wounds open to air.
- D. Administer a corticosteroid medication.
Correct Answer: A
Rationale: Oxygen supports the initial inflammatory stage by aiding cellular function, unlike corticosteroids, which delay healing.
You may also like to solve these questions
A nurse is caring for a client who has a stage 4 sacral pressure injury. The provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?
- A. Applying hydrocolloids to the wound bed.
- B. Pulsating lavage.
- C. Using a topical enzyme solution in the wound bed.
- D. Placing a transparent dressing over the pressure injury.
Correct Answer: B
Rationale: Pulsating lavage is a mechanical debridement method using a pressurized stream of fluid to remove necrotic tissue. Hydrocolloids promote autolytic debridement, enzymes are chemical, and transparent dressings do not debride.
The nurse reminds the 85-year-old patient that his healing will be slower due to age-related changes such as: (Select all that apply)
- A. Atherosclerosis
- B. Diminished lung function
- C. Excessive production of blood factors
- D. Increased immunity
- E. slow metabolism
Correct Answer: A,B,E
Rationale: A: Reduces blood flow. B: Limits oxygen delivery. E: Slows cellular repair. Immunity decreases with age (not D), and blood factors don't increase (C).
The nurse clarifies that the second stage of wound healing is:
- A. Proliferation
- B. Maturation
- C. Inflammation
- D. Remodeling
Correct Answer: A
Rationale: Proliferation is the second stage, involving granulation and epithelialization, following inflammation.
A nurse is ambulating a patient in the hall a few days after abdominal surgery when the patient says, "I think something just let go." What should be the nurse's initial intervention?
- A. Ask someone to quickly get an abdominal binder.
- B. Seat the patient in a nearby chair.
- C. Instruct the patient to pant to reduce abdominal tension.
- D. Assist the patient into a supine position.
Correct Answer: D
Rationale: Assisting to a supine position reduces strain on the abdominal wound, preventing further dehiscence.
While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?
- A. Empty the reservoir.
- B. Notify the surgeon about the drainage.
- C. Remove the drain
- D. Leave it until the end of the shift
Correct Answer: A
Rationale: Emptying the reservoir maintains drainage function and allows monitoring of output; significant changes would then prompt notifying the surgeon.