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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Abdominal pads are not designed to minimize pain during dressing changes.
Choice B rationale:
Hydrogel dressings are known to minimize pain during dressing changes.
Choice C rationale:
Wet-to-dry dressings can cause discomfort during dressing changes.
Choice D rationale:
Dry gauze can stick to the wound bed and cause pain during dressing changes.
Correct Answer is B
Explanation
Choice A rationale:
Numbing the area treated is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area.
Choice B rationale:
Dilating the blood vessels is the correct answer. Moist heat therapy works by increasing the temperature of the skin/soft tissue, which leads to vasodilation and increased blood flow to the treated area.
Choice C rationale:
Drawing fluid to the site of application is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area.
Choice D rationale:
Constricting the blood vessels is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area through vasodilation.
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