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:

Documentation is important but not the first priority.

Choice B rationale:

Assessing the patient for any complaints or problems in the wound area is the first priority in NPWT treatment.

Choice C rationale:

Checking the setting on the NPWT unit is important but comes after assessing the patient.

Choice D rationale:

Observing the dressing area when assessing vital signs is part of the assessment process but not the first priority.

A. Remind him to remain very still during the procedure. B. Place a discard bag close to the wound. C. Change gloves after removing the old dressing. D. Refrain from talking while the wound is uncovered.

Correct Answer is C

Explanation

Choice A rationale:

While it’s important for the patient to remain still during the procedure, this is not the most important aspect of changing a sterile dressing.

Choice B rationale:

Placing a discard bag close to the wound can increase the risk of infection.

Choice C rationale:

Changing gloves after removing the old dressing is crucial to maintain sterility and prevent infection.

Choice D rationale:

Refraining from talking while the wound is uncovered can help prevent infection, but it’s not as important as changing gloves after removing the old dressing.

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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

The patient is undergoing NPWT treatment for wound healing.Which would be your first priority in caring for this patient?

Correct Answer is B

Explanation

When preparing to change a sterile dressing over an incision, it is most important to remember to:

Correct Answer is C

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?