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","C","D"]

Explanation

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of pressure injuries.

Choice B rationale:

Peripheral neuropathy can lead to decreased sensation, increasing the risk of pressure injuries as the person may not feel discomfort from prolonged pressure.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases the duration of pressure on certain areas of the body.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue damage and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is within the normal range (15-36 mg/dL), so it does not increase the risk of pressure injuries.

A. Alginate. B. Dry gauze. C. Hydrogel. D. Transparent.

Correct Answer is A

Explanation

Choice A rationale:

Alginate dressings are highly absorbent and suitable for wounds with heavy drainage. They also promote hemostasis by activating the intrinsic pathway of the clotting cascade.

Choice B rationale:

Dry gauze is not the best choice for a bleeding wound as it does not have hemostatic properties.

Choice C rationale:

Hydrogel dressings are primarily for wounds with little to no exudate and not suitable for a bleeding wound.

Choice D rationale:

Transparent dressings are thin, waterproof dressings used for superficial wounds and not suitable for a bleeding wound.

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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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Correct Answer is ["B","C","D"]

Explanation

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Correct Answer is A

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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?