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Chronic wounds that are not healing well may benefit from (Select all that apply.)

Wet-to-dry dressings.

Negative pressure treatment.

NPWT therapy.

Hydrocolloid dressings.

Promoting protein in the diet.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A rationale:

Wet-to-dry dressings are not typically used for chronic wounds as they can cause tissue damage.

Choice B rationale:

Negative pressure treatment can promote healing by removing excess fluid and promoting blood flow to the wound.

Choice C rationale:

NPWT therapy, or Negative Pressure Wound Therapy, can help heal chronic wounds by removing excess fluid and promoting blood flow.

Choice D rationale:

Hydrocolloid dressings maintain a moist wound environment, which can promote healing.

Choice E rationale:

Protein is essential for wound healing as it is needed for the growth and repair of tissues.

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Correct Answer is C

Explanation

Choice A rationale:

Stage 3 pressure injuries involve full-thickness skin loss, but not exposure of fascia.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

Choice D rationale:

Stage 1 pressure injuries involve non-blanchable erythema of intact skin.

A. A client who is alert and responsive and eats 25% of each meal. B. A client who is unresponsive to verbal commands and changes position occasionally. C. A client who makes frequent slight changes in position and walks occasionally. D. A client who is receiving enteral feeding and can change position independently.

Correct Answer is B

Explanation

Choice A rationale:

An alert and responsive client who eats 25% of each meal may have nutritional deficiencies, but is able to change position to relieve pressure.

Choice B rationale:

A client who is unresponsive to verbal commands and only changes position occasionally is at high risk for pressure injury due to prolonged pressure on certain areas of the body.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is not at high risk for pressure injury.

Choice D rationale:

A client receiving enteral feeding and can change position independently is not at high risk for pressure injury.

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Chronic wounds that are not healing well may benefit from (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

Correct Answer is C

Explanation

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

Correct Answer is B

Explanation

After closing the curtain around the client's bed, you lift his gown to expose the horizontal abdominal wound and assist the client into a comfortable position for wound irrigation.Which of the following positions is appropriate for the irrigation of his wound?

A patient has a pooling of blood under unbroken skin of the hip after a fall.The nurse should document that this patient has a(n):

A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement.Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

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

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a:

A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

Superficial wounds heal faster when kept: