A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement.
Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?
applying hydrocolloids to the wound bed.
placing a transparent dressing over the pressure injury.
pulsating lavage.
using a topical enzyme solution in the wound bed.
The Correct Answer is C
Choice A rationale:
Hydrocolloids are not a form of mechanical debridement. They are dressings that promote autolytic debridement by maintaining a moist wound environment.
Choice B rationale:
Transparent dressings are not a form of mechanical debridement. They are used to protect the wound and allow for visual inspection.
Choice C rationale:
Pulsating lavage is a form of mechanical debridement. It involves using a pressurized, pulsed solution to remove necrotic tissue from the wound bed.
Choice D rationale:
Topical enzyme solutions are not a form of mechanical debridement. They are a form of chemical debridement that breaks down necrotic tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
E. Using a thermometer to check the temperature of the pad, Securing the pad to the patient, Instructing the patient not to sleep on the pad, Inspecting the plug and cord for cracks or fraying.
Choice A rationale:
It’s important to check the temperature of the pad to prevent burns.
Choice B rationale:
Securing the pad ensures it stays in place and provides consistent heat.
Choice C rationale:
Patients should not lie on top of the pad as it can lead to burns.
Choice D rationale:
Patients should not sleep on the pad to prevent prolonged exposure which can lead to burns.
Choice E rationale:
Inspecting the plug and cord prevents electrical hazards.
Correct Answer is B
Explanation
Choice A rationale:
A stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area.
Choice B rationale:
Unstageable pressure injuries are those where the base of the wound is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Choice C rationale:
Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Choice D rationale:
A stage 2 pressure injury involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.
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