A nurse is planning interventions for a client who has a chronic wound on his lower leg. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Apply a moist dressing to the wound

Assess the wound for signs of infection

Debride necrotic tissue from the wound

Elevate the affected leg above the heart level

Massage the wound edges gently

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason:

Applying a moist dressing to the wound provides a moist environment for wound healing and protects the wound from contamination and trauma. Moisture prevents dehydration and necrosis of the wound bed and promotes cell migration and growth.

Choice B reason:

Assessing the wound for signs of infection is important to detect and treat any infection that may impair wound healing or cause systemic complications. Signs of infection include increased redness, warmth, swelling, pain, drainage, odor, fever, or leukocytosis.

Choice C reason:

Debriding necrotic tissue from the wound is essential to remove any dead or devitalized tissue that may interfere with wound healing or serve as a source of infection. Debridement can be done by surgical, mechanical, enzymatic, or autolytic methods.

Choice D reason:

Elevating the affected leg above the heart level reduces edema and improves blood circulation to the wound. Edema can impair wound healing by causing tissue hypoxia, increasing bacterial growth, and delaying granulation tissue formation.

Choice E reason:

Massaging the wound edges gently is not recommended for chronic wounds, as it may cause trauma or bleeding to the wound bed or delay epithelialization. Massaging may be beneficial for preventing hypertrophic scars or contractures in healed wounds.

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Correct Answer is A

Explanation

Choice B reason:

Transparent film dressing is a type of dressing that consists of a thin sheet of polyurethane with an adhesive coating. It allows oxygen and moisture vapor to pass through but prevents bacteria and water from entering the wound. It is suitable for wounds with minimal drainage, such as superficial abrasions or donor sites.

Choice C reason:

Calcium alginate dressing is a type of dressing that consists of fibers derived from seaweed that form a gel-like substance when they come in contact with wound exudate. It absorbs large amounts of drainage and supports autolytic debridement of necrotic tissue. It is suitable for wounds with heavy drainage, such as pressure ulcers or venous ulcers.

Choice D reason:

Hydrogel dressing is a type of dressing that consists of water or glycerin-based gel that provides moisture to dry wounds and supports autolytic debridement of necrotic tissue. It is suitable for wounds with minimal to moderate drainage, such as partial-thickness burns or radiation injuries.

A. Decreased hematocrit B. Increased urine specific gravity C. Decreased central venous pressure D. Increased blood urea nitrogen

Correct Answer is A

Explanation

Choice A reason:

Decreased hematocrit is an indicator of improvement for a client who has hypovolemia and is receiving IV fluid therapy. Hematocrit is the percentage of red blood cells in the blood. Hypovolemia causes hemoconcentration, which increases the hematocrit level. IV fluid therapy restores the blood volume and dilutes the red blood cells, which decreases the hematocrit level.

Choice B reason:

Increased urine specific gravity is not an indicator of improvement for a client who has hypovolemia and is receiving IV fluid therapy. Urine specific gravity is a measure of the concentration of solutes in the urine. Hypovolemia causes dehydration, which increases the urine specific gravity. IV fluid therapy rehydrates the body and lowers the urine specific gravity.

Choice C reason:

Decreased central venous pressure is not an indicator of improvement for a client who has hypovolemia and is receiving IV fluid therapy. Central venous pressure is a measure of the pressure in the right atrium and vena cava. Hypovolemia causes decreased preload, which lowers the central venous pressure. IV fluid therapy increases preload and raises the central venous pressure.

Choice D reason:

Increased blood urea nitrogen is not an indicator of improvement for a client who has hypovolemia and is receiving IV fluid therapy. Blood urea nitrogen is a measure of the amount of urea in the blood. Urea is a waste product of protein metabolism that is excreted by the kidneys. Hypovolemia causes decreased renal perfusion, which increases the blood urea nitrogen level. IV fluid therapy improves renal perfusion and lowers the blood urea nitrogen level.

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