Select the 5 findings that can cause delayed wound healing.

History of diabetes mellitus.

History of hyperlipidemia.

Wound infection.

Decreased pedal perfusion.

Fasting blood glucose.

Answer and Explanation

Correct Answer : A,B,C,D,E

Choice A rationale

A history of diabetes mellitus can cause delayed wound healing due to poor blood circulation and neuropathy, which can lead to reduced sensation and increased risk of infection.

Choice B rationale

A history of hyperlipidemia can contribute to delayed wound healing by causing atherosclerosis, which reduces blood flow to the wound site and impairs healing.

Choice C rationale

Wound infection is a direct cause of delayed wound healing. Infection can lead to increased inflammation, tissue damage, and prolonged healing time.

Choice D rationale

Decreased pedal perfusion indicates poor blood flow to the lower extremities, which can significantly delay wound healing by reducing the delivery of oxygen and nutrients to the wound.

Choice E rationale

Fasting blood glucose levels are important to monitor in patients with diabetes, as high glucose levels can impair the body’s ability to heal wounds effectively.

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Correct Answer is A

Explanation

Choice A rationale

The weights from the traction device should only be removed if the client develops a life- threatening situation. This is to ensure the client’s immediate safety and address the critical condition.

Choice B rationale

The client should not have the weights removed for repositioning in the bed. Proper techniques should be used to reposition the client without removing the weights to maintain the effectiveness of the traction.

Choice C rationale

Complaints of pain should be addressed by assessing the cause and providing appropriate pain management, but the weights should not be removed as it can compromise the traction.

Choice D rationale

The weights should not be removed for an x-ray. The traction can be maintained during imaging procedures to ensure continuous treatment.

A. Medicate for pain. B. Maintain the airway. C. Insert an indwelling urinary catheter. D. Initiate fluid resuscitation.

Correct Answer is B

Explanation

Choice A rationale

While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.

Choice B rationale

Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.

Choice C rationale

Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.

Choice D rationale

Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.

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Select the 5 findings that can cause delayed wound healing.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skin traction. The nurse may remove the weights from the traction device if which of the following occurs?

Correct Answer is A

Explanation

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?

Correct Answer is B

Explanation

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