A patient is incontinent the first day after his surgery.
This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:
The patient has to be repositioned for the bed to be changed.
Shearing is more likely from wet sheets.
The moisture creates an environment suitable for the growth of microorganisms in a wound.
Greater pressure is exerted by a wet bed.
The Correct Answer is C
Choice A rationale:
Repositioning the patient for bed changing does not directly contribute to skin breakdown or infection.
Choice B rationale:
While shearing can cause skin breakdown, it is not directly related to incontinence or wet sheets.
Choice C rationale:
Moisture from incontinence can create an environment suitable for the growth of microorganisms in a wound, leading to infection and skin breakdown.
Choice D rationale:
A wet bed does not exert greater pressure on the patient’s skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Hydrocolloids are not a form of mechanical debridement. They are dressings that promote autolytic debridement by maintaining a moist wound environment.
Choice B rationale:
Transparent dressings are not a form of mechanical debridement. They are used to protect the wound and allow for visual inspection.
Choice C rationale:
Pulsating lavage is a form of mechanical debridement. It involves using a pressurized, pulsed solution to remove necrotic tissue from the wound bed.
Choice D rationale:
Topical enzyme solutions are not a form of mechanical debridement. They are a form of chemical debridement that breaks down necrotic tissue.
Correct Answer is D
Explanation
Choice A rationale:
Massaging bony prominences can lead to tissue ischemia and damage, increasing the risk of pressure injuries.
Choice B rationale:
Repositioning should be done every 2 hours or less for at-risk patients.
Choice C rationale:
Elevating the head of the bed more than 30° can increase shear and friction, leading to pressure injuries.
Choice D rationale:
A high-calorie diet can promote skin integrity and wound healing.
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