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","C","D"]
Explanation
E.
Choice A rationale:
Proper nutrition with adequate protein and vitamin C is essential for wound healing as these nutrients are needed for collagen synthesis.
Choice B rationale:
Resting as much as possible and keeping the incisional area still may not necessarily aid in healing. Movement can actually promote circulation and healing.
Choice C rationale:
Increasing fluid intake to at least 4000 mL per day can help keep the body hydrated, which is beneficial for wound healing.
Choice D rationale:
Keeping skin and surrounding tissue clean and dry can help prevent infection, which can delay wound healing.
Choice E rationale:
Exercise and deep breathing can increase oxygenation, which is beneficial for wound healing.
Correct Answer is B
Explanation
Choice A rationale:
Documentation is important but not the first priority.
Choice B rationale:
Assessing the patient for any complaints or problems in the wound area is the first priority in NPWT treatment.
Choice C rationale:
Checking the setting on the NPWT unit is important but comes after assessing the patient.
Choice D rationale:
Observing the dressing area when assessing vital signs is part of the assessment process but not the first priority.
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