A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

Removing excess drainage and wet tissue to prevent maceration of surrounding skin

Stimulating the wound bed to promote the growth of granulation tissue

Removing purulent drainage from the wound bed in order to accurately assess it

Removing dead or infected tissue to promote wound healing

Answer and Explanation

The Correct Answer is D

Choice A rationale: Removing excess drainage and wet tissue to prevent maceration is more related to wound care than debridement.
Choice B rationale: Stimulating the wound bed to promote the growth of granulation tissue is a goal of debridement.
Choice C rationale: Removing purulent drainage from the wound bed is more related to wound care than debridement.
Choice D rationale: The primary goal of debridement is to remove dead or infected tissue to promote wound healing and create an environment conducive to tissue regeneration.

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Correct Answer is ["A","D","E"]

Explanation

Choice A rationale: Contractures are a common complication of immobility due to the shortening of muscles and connective tissues.
Choice B rationale: Diarrhea is not typically associated with complications of immobility.
Choice C rationale: Polyuria is not typically associated with complications of immobility.
Choice D rationale: Atelectasis, the collapse of lung tissue, can occur in immobile clients due to reduced lung expansion and ventilation.
Choice E rationale: Pressure ulcers are a significant risk in immobile clients due to prolonged pressure on specific areas of the body.

A. Unintentional closed wound B. Intentional closed wound C. Intentional open wound D. Unintentional open wound

Correct Answer is D

Explanation

Choice A rationale: Unintentional closed wounds involve blunt force trauma but do not typically result in jagged edges with muscle tissue visible.
Choice B rationale: Intentional closed wounds are typically surgical incisions and do not present with jagged edges and visible muscle tissue.
Choice C rationale: Intentional open wounds are typically surgical incisions, not the result of a biking accident.
Choice D rationale: Unintentional open wounds result from accidents and can present with jagged edges and visible tissue.

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A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible after a biking accident. The nurse should document this as which of the following types of wounds?

Correct Answer is D

Explanation

When moving a client up in bed with the assistance of another caregiver, the nurse should:

Doctor's order: 750 mL NS to infuse over 8 hours. How many mL/hr will you set the IV pump? Round to the nearest whole number.

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

The nurse is leading an exercise class for a group of adults aged 65 years and older. The nurse incorporates isotonic. Isometric, and isokinetic exercises into the class. Which activity is an isometric exercise?

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?