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

Explanation

Choice A rationale: A deep tissue injury involves intact skin with a purple or maroon localized area of discolored, non-blanchable, deep red or maroon, or a blood-filled blister due to damage of underlying soft tissue from pressure or shear. It is a stage that is more appropriate for the described wound involving the epidermis and dermis.
Choice B rationale: Stage III pressure ulcers involve full-thickness tissue loss, but they do not involve the epidermis and dermis.
Choice C rationale: Unstageable ulcers are covered with slough or eschar, making it difficult to determine the depth of tissue involvement. In this case, the wound's description indicates involvement of the epidermis and dermis.
Choice D rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, not just the epidermis and dermis.

A. A client who is confined to bedrest. B. A client who has leg strength and can cooperate with the movement C. A client who has a thoracic incision. D. A client who has an abdominal incision.

Correct Answer is B

Explanation

Choice A rationale: A client who is confined to bedrest may not need a gait belt as they are not ambulating.
Choice B rationale: A client with leg strength who can cooperate with movement is a likely candidate for a gait belt. This device provides support and stability during ambulation.
Choice C rationale: A client with a thoracic incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.
Choice D rationale: A client with an abdominal incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.

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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 completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?

Correct Answer is A

Explanation

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

Correct Answer is B

Explanation

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