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

Answer and Explanation

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.

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Correct Answer is ["3"]

Explanation

Step-by-Step Calculation:

Step 1: Determine the dose required.

Dose required = 1.5 mg

Step 2: Determine the dose available per tablet.

Dose available per tablet = 0.5 mg

Step 3: Calculate the number of tablets needed.

Number of tablets = Dose required ÷ Dose available per tablet
Number of tablets = 1.5 mg ÷ 0.5 mg/tablet

Step 4: Perform the division.

1.5 ÷ 0.5 = 3

Result: The nurse should administer 3 tablets.

Therefore, the nurse should administer 3 tablets.

A. Secure the oxygen tubing to the bed sheet near the client’s head. B. Attach a humidifier bottle to the base of the flow meter. C. Apply petroleum jelly to the nares as needed to soothe mucous membranes. D. Remove the nasal cannula while the client eats.

Correct Answer is B

Explanation

Choice A Reason:

Securing the oxygen tubing to the bed sheet near the client’s head is not recommended because it can lead to accidental dislodgement of the tubing, which can interrupt the oxygen supply. Additionally, this practice does not address the potential for nasal dryness and irritation that can occur with oxygen therapy. Properly securing the tubing should involve ensuring it is comfortably positioned and not at risk of being pulled or dislodged.

Choice B Reason:

Attaching a humidifier bottle to the base of the flow meter is the correct action because it helps to add moisture to the oxygen being delivered to the client. Oxygen therapy, especially at higher flow rates like 5 L/min, can dry out the nasal passages and mucous membranes, leading to discomfort and potential complications. The humidifier bottle ensures that the oxygen is humidified, which helps to prevent dryness and irritation, making the therapy more comfortable and effective for the client.

Choice C Reason:

Applying petroleum jelly to the nares is not recommended because petroleum-based products can be flammable and pose a risk when used in conjunction with oxygen therapy. Additionally, petroleum jelly can trap bacteria and potentially lead to infections. Instead, water-based lubricants or saline nasal sprays are safer alternatives for soothing dry nasal passages.

Choice D Reason:

Removing the nasal cannula while the client eats is not advisable because it interrupts the continuous delivery of oxygen, which is essential for clients with pneumonia who may already have compromised respiratory function. Instead, the nurse should ensure that the nasal cannula is securely in place and that the client is receiving the prescribed oxygen therapy at all times, including during meals.

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A nurse is assessing a client’s wound and notes there is slough present. What would be an appropriate intervention for this wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin 1.5 mg PO to a client. The amount available is digoxin 0.5 mg tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["3"]

Explanation

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which action should the nurse take?

Correct Answer is B

Explanation

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