A client's orders include a wound dressing using an autolytic debriding agent. The nurse providing discharge instructions to the client should include which statement?
Keep the dressing very wet at all times.
Do not use a dressing 6 hours/day.
Cleanse the wound with Dakin's solution.
The wound may have a foul odor.
The Correct Answer is D
Choice A rationale
Keeping the dressing very wet at all times is not advisable with autolytic debriding agents. Excess moisture can cause maceration of the surrounding skin and increase the risk of infection. The dressing should maintain an optimal level of moisture to promote autolysis without causing harm.
Choice B rationale
Not using a dressing for 6 hours/day is incorrect advice. Continuous application of the dressing is essential for the autolytic process. Removing the dressing for extended periods disrupts the environment needed for autolysis, delaying wound healing.
Choice C rationale
Cleansing the wound with Dakin's solution is not recommended with autolytic debridement. Dakin's solution is a chemical debriding agent, and its use can interfere with the natural autolytic process. It is better to use saline or appropriate cleansers as directed.
Choice D rationale
The wound may have a foul odor due to the autolytic debridement process. As dead tissue is broken down, it can produce a distinct odor. Educating the client about this expected outcome helps them understand that it is a normal part of the healing process and not necessarily a sign of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Techniques for performing neck ROM exercises might be relevant but are secondary to the immediate postoperative care following a cervical discectomy.
Choice B rationale
Restoring nerve function is a goal but not directly linked to discharge education strategies after cervical discectomy.
Choice C rationale
Home assessment of ABGs is not relevant to discharge education for a cervical discectomy, as it pertains more to respiratory status monitoring.
Choice D rationale
Care of the cervical collar is essential post-discectomy as it provides stability, reduces strain on the cervical spine, and supports the healing process, making it a critical part of discharge education.
Correct Answer is C
Explanation
Choice A rationale
Aspiration of synovial fluid for serologic testing is a procedure known as arthrocentesis, which involves extracting joint fluid for analysis. While useful for diagnosing conditions like infections or arthritis, it is not the same as arthrography, which involves imaging.
Choice B rationale
Injection of corticosteroids into the client's knee joint to facilitate ROM is a therapeutic procedure to reduce inflammation and improve movement in conditions like arthritis, but it is not part of an arthrography procedure.
Choice C rationale
Injection of a contrast agent into the knee joint prior to ROM exercises is a key part of arthrography. The contrast agent helps to enhance the imaging of the joint structures during movement, allowing for a detailed assessment of the joint.
Choice D rationale
Replacement of the client's synovial fluid with a synthetic substitute is not related to arthrography. This description aligns more with viscosupplementation, a treatment for osteoarthritis.
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