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: Voiding and discarding the urine is the first step in a 24-hour urine collection to ensure that the collection starts with a fresh specimen.
Choice B rationale: Adding the first voiding to the specimen is not the correct initial step.
Choice C rationale: Keeping the urine warm during collection is important, but it is not the first step in the process.
Choice D rationale: Beginning the collection at a specific time is part of the process but not the initial step.

A. The patient may have paralytic ileus that could last 3-5 days B. It is normal for all post-op patients not to have bowel sounds C. The absence of bowel sounds is an abnormal finding D. Document absent bowel sounds and notify the physician

Correct Answer is A

Explanation

Choice A rationale: The absence of bowel sounds on post-operative day 2 may indicate paralytic ileus, which is a temporary impairment of bowel motility. Paralytic ileus can last for 3-5 days postoperatively and is considered a normal response to surgery.
Choice B rationale: It is not normal for all post-op patients to have absent bowel sounds on day 2. Bowel sounds should typically return within the first 24 hours after surgery.
Choice C rationale: The absence of bowel sounds can be a normal finding in the immediate postoperative period, especially within the first 24 hours. However, it becomes abnormal if prolonged.
Choice D rationale: Documenting absent bowel sounds is appropriate, but notifying the physician should be based on the overall clinical picture and other symptoms.

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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 initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?

Correct Answer is A

Explanation

A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

Correct Answer is A

Explanation

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

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?

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

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A client with a urinary tract infection is to be discharged from the healthcare facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client makes which statement?

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

Reflex incontinence is associated with neurologic dysfunction and occurs when no warning or stress precedes periodic involuntary urination.

The nurse is caring for a client with a wound from a biking accident. She assesses the wound and notices that the surrounding skin is very red and warm. The wound looks swollen and is draining a green like drainage. The nurse would recognize these symptoms would be a sign of what?