A nurse is caring for a client who has an open abdominal wound and a negative-pressure wound therapy (NPWT) device. Which of the following actions should the nurse take?
Replace the NPWT dressing every 12 hours.
Allow the wound to be open to air at least once per shift.
Shave the skin around the wound prior to applying the wound therapy device.
If client reports pain, decrease the suction to 75 mm Hg.
The Correct Answer is D
Rationale
A. Replace the NPWT dressing every 12 hours: NPWT dressings are typically changed every 48–72 hours, or sooner if the dressing is saturated or malfunctioning. Changing the dressing every 12 hours is excessive and can disrupt wound healing and increase infection risk.
B. Allow the wound to be open to air at least once per shift: Negative-pressure wound therapy requires a sealed environment to maintain suction and promote healing. Exposing the wound to air would compromise negative pressure, delay healing, and increase infection risk.
C. Shave the skin around the wound prior to applying the wound therapy device: Shaving can cause microabrasions and increase the risk of infection. Hair should be gently trimmed if necessary, but shaving is not recommended prior to applying NPWT dressings.
D. If client reports pain, decrease the suction to 75 mm Hg: Pain during NPWT can occur if suction pressure is too high. Reducing suction to 75 mm Hg helps minimize discomfort while maintaining therapeutic negative pressure. Adjusting suction appropriately promotes client comfort and adherence to therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","G"]
Explanation
Rationale
A. Reposition the client every 3 hr: Repositioning should be done every 2 hours for clients at risk of skin breakdown, not every 3 hours. Longer intervals increase the risk of pressure injuries, particularly in clients with limited mobility and incontinence.
B. Place the client on a donut-shaped cushion: Donut-shaped cushions can actually increase pressure on surrounding tissue and contribute to skin breakdown. Pressure-redistribution surfaces are safer and more effective for preventing pressure injuries.
C. Elevate the head of the bed to 45°: Elevating the head of the bed to no more than 30–45° reduces the risk of shear and friction on the sacral area while promoting comfort. Proper positioning helps protect skin integrity, especially in incontinent clients.
D. Request a consult with a registered dietitian: Adequate nutrition is essential for skin health and healing. A dietitian can provide recommendations to ensure sufficient protein, calories, and nutrients to support skin integrity and prevent pressure injuries in clients with diabetes and limited mobility.
E. Provide a support pressure-redistribution surface: Specialty mattresses or overlays redistribute pressure over bony prominences, reducing the risk of pressure injuries. These surfaces are critical for clients who are immobile or incontinent.
F. Perform a skin risk assessment weekly: Skin assessments should be performed daily, not weekly, for clients at high risk. Frequent assessment allows early detection of pressure injury development.
G. Use a moisture barrier ointment after cleaning the client's skin: Barrier ointments protect the skin from moisture associated with urinary and fecal incontinence. Regular application after cleansing helps prevent moisture-associated skin damage and breakdown.
Correct Answer is C
Explanation
Rationale
A. Encourage the oncoming shift nurse to contact the provider with any questions: While the oncoming nurse may need to contact the provider, relying on this step alone does not ensure a comprehensive or standardized handoff. Important information may be missed if the report is informal or incomplete.
B. Record a verbal report on a recorder for the oncoming nurse to listen to: Using a recording is not ideal because it prevents real-time clarification and questions. Direct communication is necessary to address immediate concerns and confirm understanding for safe continuity of care.
C. Use a standardized approach to giving the handoff report: Utilizing a standardized method, such as SBAR (Situation, Background, Assessment, Recommendation), ensures that essential information is communicated clearly, consistently, and completely. This approach reduces errors and promotes continuity of care between shifts.
D. Provide the handoff report at the nurses' station: Providing a report at the nurses’ station may compromise privacy and lead to distractions. Bedside handoff or a private setting allows for a more thorough and interactive exchange of information, supporting safety and continuity.
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