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
Explanation
Choice A rationale:
An unresponsive client who only occasionally changes position is at the highest risk for developing a pressure injury due to prolonged pressure on certain areas of the body.
Choice B rationale:
A client who is alert and responsive and eats 25% of each meal is at lower risk as they are likely to move more frequently.
Choice C rationale:
A client who makes frequent slight changes in position and walks occasionally is at lower risk due to regular movement.
Choice D rationale:
A client who is receiving enteral feeding and can change position independently is at lower risk as they are able to relieve pressure regularly.
Correct Answer is ["B","C","D","E"]
Explanation
E.
Choice A rationale:
A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of a pressure injury.
Choice B rationale:
Peripheral neuropathy can lead to a loss of sensation, which increases the risk of a pressure injury as the individual may not feel discomfort or recognize the need to reposition.
Choice C rationale:
Immobility is a major risk factor for pressure injuries as it increases pressure on certain areas of the body, reducing blood flow and leading to tissue damage.
Choice D rationale:
Hypoperfusion, or reduced blood flow, can lead to tissue hypoxia and increase the risk of pressure injuries.
Choice E rationale:
A prealbumin level of 16 mg/dL is at the lower end of the normal range (15-36 mg/dL)2. Low prealbumin levels can indicate poor nutritional status, which is a risk factor for pressure injuries.
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