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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Decreased serum calcium does not directly contribute to pressure injury development.

Choice B rationale:

Decreased circulation can lead to tissue ischemia and necrosis, increasing the risk of pressure injury.

Choice C rationale:

Increased collagen is beneficial for wound healing and does not increase the risk of pressure injury.

Choice D rationale:

Increased muscle mass can actually provide more padding over bony prominences, reducing the risk of pressure injury.

A. Refrains from touching the drainage spout with the hand. B. Uses one alcohol wipe to clean both the spout and the plug. C. Points the device away from herself while opening it. D. Compresses the device in the hand before closing.

Correct Answer is B

Explanation

Choice A rationale:

Refraining from touching the drainage spout with the hand is a correct practice. This helps to prevent contamination of the drain.

Choice B rationale:

Using one alcohol wipe to clean both the spout and the plug is incorrect. Each part should be cleaned with a separate alcohol wipe to prevent cross-contamination.

Choice C rationale:

Pointing the device away from oneself while opening it is a correct practice. This helps to prevent accidental exposure to the drainage fluid.

Choice D rationale:

Compressing the device in the hand before closing is a correct practice. This helps to maintain the suction in the drain.

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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?

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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?