A nurse is assessing a client’s wound and notes there is slough present. What would be an appropriate intervention for this wound?
Cover
Clean
Debride
Leave alone
The Correct Answer is C
Choice A reason: Cover
Covering a wound with slough is not an appropriate intervention. Slough is a type of necrotic tissue that can impede the healing process by providing a medium for bacterial growth and preventing the formation of healthy granulation tissue. Simply covering the wound without addressing the slough can lead to infection and delayed healing.
Choice B reason: Clean
Cleaning the wound is a necessary step in wound care, but it is not sufficient on its own to address the presence of slough. While cleaning can help reduce the bacterial load and remove some debris, it does not effectively remove the slough itself. Slough often requires more targeted interventions such as debridement to be effectively managed.
Choice C reason: Debride
Debridement is the most appropriate intervention for a wound with slough. Debridement involves the removal of necrotic tissue, including slough, to promote a clean wound bed and facilitate the healing process. There are several methods of debridement, including autolytic, enzymatic, mechanical, and surgical, each with its own indications and benefits. Removing the slough allows for better assessment of the wound and promotes the formation of healthy granulation tissue.
Choice D reason: Leave Alone
Leaving a wound with slough alone is not advisable. Slough can harbor bacteria and impede the healing process, leading to chronic wounds and potential infection. Without intervention, the wound is unlikely to progress through the normal stages of healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Cardiac monitoring involves the continuous observation of the heart’s electrical activity, typically using an electrocardiogram (ECG). While cardiac monitoring is essential for detecting arrhythmias and other cardiac events, it does not directly measure fluid retention. Fluid retention in CHF patients can lead to symptoms such as edema and weight gain, which are not directly assessed through cardiac monitoring.
Choice B Reason:
Daily weight measurement is a reliable and practical method for assessing fluid retention in clients with congestive heart failure. Fluid retention leads to an increase in body weight, and monitoring daily weight changes can help detect fluid accumulation early. A sudden weight gain of more than 2-3 pounds in a day or 5 pounds in a week is a significant indicator of fluid retention and worsening heart failure. This method is non-invasive, easy to perform, and provides valuable information for managing CHF.
Choice C Reason:
Blood pressure monitoring is crucial for managing clients with CHF, as hypertension can exacerbate heart failure. However, blood pressure readings alone do not provide a direct measure of fluid retention. While fluid overload can affect blood pressure, it is not a specific or sensitive indicator of fluid status. Blood pressure monitoring should be used in conjunction with other assessment tools to manage CHF effectively.
Choice D Reason:
Urine output measurement is an important parameter for assessing kidney function and fluid balance. In clients with CHF, reduced urine output can indicate worsening heart failure and fluid retention. However, urine output alone may not provide a complete picture of fluid status, especially if the client is on diuretic therapy. Daily weight measurement remains a more direct and reliable method for assessing fluid retention in CHF patients.
Correct Answer is B
Explanation
Choice A reason: A history of hypothyroidism is not a contraindication for magnet therapy. Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone, but it does not interfere with the use of magnetic fields. Therefore, patients with hypothyroidism can safely use magnet therapy.
Choice B reason: Having a pacemaker is a significant contraindication for magnet therapy. Magnetic fields can interfere with the functioning of pacemakers, potentially leading to serious complications. Patients with pacemakers should avoid magnet therapy to prevent any risk of device malfunction.
Choice C reason: A history of narcolepsy is not a contraindication for magnet therapy. Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness, but it does not interact with magnetic fields. Therefore, patients with narcolepsy can use magnet therapy without concern.
Choice D reason: An indwelling catheter is not a contraindication for magnet therapy. Indwelling catheters are used for urinary drainage and do not interact with magnetic fields4. Patients with indwelling catheters can safely undergo magnet therapy.
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