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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale

A. "My hearing has improved since I got my hearing aids.": This statement reflects a positive adaptation to age-related sensory changes and does not indicate a disturbed body image. The client demonstrates acceptance and use of assistive devices to maintain function.

B. "I avoid going out because I sometimes have problems with incontinence.": Avoiding social situations due to incontinence suggests the client is experiencing distress or embarrassment about physical changes, reflecting an impaired body image. This avoidance can affect self-esteem, social engagement, and overall quality of life.

C. "These lines in my face reveal a part of my character.": This statement shows the client has a positive perception of aging and views physical changes as meaningful rather than negative, indicating a healthy body image.

D. "My wrinkled hands show how hard I've worked all my life.": The client interprets physical aging positively, associating wrinkles with experience and effort, which demonstrates acceptance of bodily changes and a preserved body image.

A. Lethargy B. Constipation C. Positive Chvostek's sign D. Muscle flaccidity

Correct Answer is C

Explanation

Rationale

A. Lethargy: Lethargy is more commonly associated with hypercalcemia, which depresses the central nervous system. In hypocalcemia, neuromuscular excitability is increased, so clients are more likely to experience irritability or paresthesia rather than lethargy.

B. Constipation: Constipation is a manifestation of hypercalcemia due to decreased smooth muscle contractility. Hypocalcemia typically increases neuromuscular excitability and does not generally cause constipation.

C. Positive Chvostek's sign: A positive Chvostek's sign indicates facial muscle twitching in response to tapping over the facial nerve and is a hallmark sign of hypocalcemia. It reflects increased neuromuscular excitability due to low calcium levels and is commonly used in assessment.

D. Muscle flaccidity: Muscle flaccidity occurs with hypercalcemia or decreased neuromuscular activity. In hypocalcemia, muscles are more likely to exhibit tetany, spasms, or cramping due to heightened excitability, rather than flaccidity.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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