A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Apply oxygen at 2 L/min via nasal cannula.

Initiate mechanical debridement.

Leave non-bleeding wounds open to air.

Administer a corticosteroid medication.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Applying oxygen at 2 L/min via nasal cannula is not typically indicated in the initial stage of wound healing. Oxygen therapy is used for clients with respiratory distress or hypoxia, not as a standard wound care procedure.

Choice B rationale
Mechanical debridement is a method used to remove dead tissue from wounds, but it is not usually part of the initial wound care plan. Debridement is considered when there is necrotic tissue present that may impede healing.

Choice C rationale
Leaving non-bleeding wounds open to air can be beneficial during the initial stage of wound healing. Exposure to air can help to dry out the wound and prevent maceration of the surrounding skin. It also allows for the observation of the wound and easy access for dressing changes if needed.

Choice D rationale
Administering a corticosteroid medication is not a standard part of initial wound care. Corticosteroids can actually delay wound healing and are generally avoided unless there is a specific indication, such as an inflammatory skin condition.

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Correct Answer is C

Explanation

Choice A rationale
When administering a hot soak treatment, it is crucial to soak only the affected area to provide targeted heat therapy. This localized approach helps to increase blood flow, reduce pain, and promote healing in the specific area that requires treatment. Soaking only the affected area also minimizes the risk of overheating and potential burns to other parts of the body.

Choice B rationale
While positioning the patient comfortably is important for any treatment, it is not the most critical aspect of a hot soak treatment. Comfort should always be considered, but the primary goal of the hot soak is to apply heat to the affected area to aid in healing. Therefore, ensuring that only the affected area is soaked takes precedence over general patient comfort in this context.

Choice C rationale
Monitoring the temperature of the water is the most important aspect of a hot soak treatment. The water must be warm enough to be therapeutic but not so hot as to cause burns or discomfort. This ensures the treatment is both safe and effective1.

Choice D rationale
Checking the patient’s skin integrity is important, especially if the patient has a condition that affects skin sensitivity, such as diabetes. However, the immediate concern during a hot soak treatment is to monitor the temperature to prevent injury.

A. Keep the wound dry. B. Leave the dressing in place for 7 days. C. Help destroy microorganisms in an infected wound. D. Promote a moist healing environment.

Correct Answer is D

Explanation

Choice A rationale
Hydrocolloid dressings are not designed to keep a wound dry; instead, they maintain a moist environment which is conducive to wound healing. They absorb exudate and form a gel, which promotes granulation and epithelialization.

Choice B rationale
The primary purpose of a hydrocolloid dressing is to remain in place for an extended period, typically up to 7 days. This minimizes disturbance to the wound, reduces the risk of infection, and maintains a moist healing environment.

Choice C rationale
While hydrocolloid dressings can help prevent bacterial growth due to their occlusive nature, their main function is not to destroy microorganisms. They provide a barrier against external contaminants and support autolytic debridement.

Choice D rationale
The main purpose of hydrocolloid dressings is to promote a moist healing environment. They contain gel-forming agents that absorb exudate and maintain a moist wound bed, which facilitates faster healing and reduced scar formation.

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A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When giving a hot soak treatment, what is most important to ensure?

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

When applying an ice pack, it is necessary to:

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What stage is a wound if the epidermis is closed and has unblanchable redness?

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?