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.

None

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D.

Choice A rationale: Leaving nonbleeding wounds open to air increases the risk of infection and delayed healing. Wounds need a moist environment to promote cell migration and collagen synthesis, essential for the initial inflammatory phase of healing.

Choice B rationale: Corticosteroids suppress the immune response and inflammation, which can delay wound healing. They inhibit leukocyte migration and fibroblast proliferation, which are crucial during the initial stage of the healing process.

Choice C rationale: Mechanical debridement is typically used for chronic wounds with necrotic tissue. In the initial stage of wound healing, it is not necessary and could damage newly formed tissue, delaying the healing process.

Choice D rationale: Oxygen therapy at 2L/min via nasal cannula enhances tissue oxygenation, promoting cellular activities such as collagen synthesis, angiogenesis, and leukocyte function, which are critical during the initial inflammatory phase of wound healing.

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Correct Answer is B

Explanation

Choice A rationale:

Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.

Choice B rationale:

Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.

Choice C rationale:

Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

Choice D rationale:

Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

A. moist. B. have a wet-to-dry dressing applied. C. occluded. D. debrided.

Correct Answer is A

Explanation

Choice A rationale:

Superficial wounds heal faster when kept moist.

Choice B rationale:

Wet-to-dry dressings are not typically used for superficial wounds as they can cause trauma to the wound bed during removal.

Choice C rationale:

Occlusion can help maintain a moist environment, but it’s not the only factor in wound healing.

Choice D rationale:

Debridement is the removal of dead or infected tissue from a wound, which can promote healing, but it’s not the only factor.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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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?