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?

Leave nonbleeding wounds open to air.

Administer a corticosteroid medication.

Initiate mechanical debridement.

Apply oxygen at 2L/min via nasal cannula.

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A: Leave nonbleeding wounds open to air.

Choice A rationale:

During the initial stage of wound healing, also known as the inflammatory phase, it is important to keep nonbleeding wounds clean and dry, and exposed to air to promote healing and prevent infection.

Choice B rationale:

Administering a corticosteroid medication is not typically part of the initial wound care plan, as corticosteroids can suppress the immune response and delay healing.

Choice C rationale:

Mechanical debridement is used to remove dead tissue from a wound, but it is not usually part of the initial care plan unless there is a need to clean the wound of necrotic tissue.

Choice D rationale:

Applying oxygen at 2L/min via nasal cannula is not a standard part of initial wound care. Oxygen therapy is typically reserved for patients with specific respiratory conditions or severe hypoxemia.

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Correct Answer is C

Explanation

Choice A rationale:

Cleaning from left to right across the wound can introduce bacteria from the surrounding skin into the wound, which can lead to infection.

Choice B rationale:

Cleaning from the outer abdomen toward the wound can also introduce bacteria from the surrounding skin into the wound.

Choice C rationale:

Cleaning in a circular motion around the wound, circling to the outside, helps to move bacteria away from the wound and reduce the risk of infection.

Choice D rationale:

Cleaning directly over the wound can disrupt the healing process and potentially introduce bacteria into the wound.

A. The patient has to be repositioned for the bed to be changed. B. Shearing is more likely from wet sheets. C. The moisture creates an environment suitable for the growth of microorganisms in a wound. D. Greater pressure is exerted by a wet bed.

Correct Answer is C

Explanation

Choice A rationale:

Repositioning the patient for bed changing does not directly contribute to skin breakdown or infection.

Choice B rationale:

While shearing can cause skin breakdown, it is not directly related to incontinence or wet sheets.

Choice C rationale:

Moisture from incontinence can create an environment suitable for the growth of microorganisms in a wound, leading to infection and skin breakdown.

Choice D rationale:

A wet bed does not exert greater pressure on the patient’s skin.

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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?