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A nurse is collecting data on a client who has impaired mobility.
The nurse should monitor the client for a pressure injury due to which of the following factors?

Decreased serum calcium.

Decreased circulation.

Increased collagen.

Increased muscle mass.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is C

Explanation

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.

A. Leave it until the end of the shift. B. Remove the drain. C. Empty the reservoir. D. Notify the surgeon about the blood loss.

Correct Answer is C

Explanation

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

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A nurse is collecting data on a client who has impaired mobility.The nurse should monitor the client for a pressure injury due to which of the following factors?

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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?

Correct Answer is C

Explanation

While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood.Which is the appropriate action for you to take at this time?

Correct Answer is C

Explanation

A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place.As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

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Enter instructional text.The nurse clarifies that the second stage of wound healing is:

A 28-year-old male is a patient at your clinic.He states that he had a minor accident with his motorcycle 5 days ago.He sustained several scrapes and wounds.The wound on his calf has a pinkish-red center area that looks bumpy.This indicates that the wound is:

Chronic wounds that are not healing well may benefit from (Select all that apply.)

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

Safety factors involved in using an Aquathermia pad unit for a patient include (Select all that apply.)

A nurse is collecting data on a client who has impaired mobility.
The nurse should monitor the client for a pressure injury due to which of the following factors?