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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Documenting wound size includes measuring the length, width, and depth of the wound to track the healing process and plan appropriate interventions.

Choice B rationale

The wound bed should be assessed for tissue type (granulation, slough, or eschar), color, and the presence of any exudate or infection.

Choice C rationale

The periwound skin is the area around the wound which should be assessed for color, temperature, swelling, and signs of maceration or excoriation.

Choice D rationale

Pattern of eruption is more relevant to dermatological conditions such as rashes or lesions, and not a primary focus for documenting acute open wounds.

A. "You may experience progressive deterioration in all voluntary muscles.”. B. "The strength of your arms and pelvic muscles will decrease gradually, but this should cause only slight disability.”. C. "You should ask your health care provider about that.”. D. "This form of muscular dystrophy is a relatively benign disease that progresses slowly.”. .

Correct Answer is A

Explanation

Choice A rationale

Mixed muscular dystrophy leads to progressive deterioration in all voluntary muscles, causing increasing disability over time.

Choice B rationale

This statement is incorrect because mixed muscular dystrophy affects more than just the arms and pelvic muscles and leads to significant disability.

Choice C rationale

This is not an appropriate response as it does not provide any information and deflects the client's question.

Choice D rationale

Mixed muscular dystrophy is not considered benign, as it causes significant and progressive muscle deterioration.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse documenting an acute open wound should include which characteristics? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond?

Correct Answer is A

Explanation

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