The nurse places Dakin’s solution in a wound for which purpose?
Chemical debridement
Healing
Phagocytosis
Primary intention
The Correct Answer is A
Choice A rationale
Dakin’s solution is an antiseptic containing sodium hypochlorite, used in chemical debridement to clean wounds and remove dead tissue. It helps to reduce the bacterial load and prepares the wound bed for healing by removing non-viable tissue.
Choice B rationale
While Dakin’s solution aids in the overall healing process by cleaning the wound, it does not directly cause healing. Healing is a complex process involving tissue regeneration and repair, which Dakin’s solution supports indirectly.
Choice C rationale
Phagocytosis is a part of the immune response where cells engulf and digest pathogens and debris. Dakin’s solution does not induce phagocytosis but can reduce the microbial load, making it easier for immune cells to clear the wound.
Choice D rationale
Primary intention refers to the direct healing of a wound with minimal tissue loss, typically through suturing. Dakin’s solution is not used for primary intention but for treating wounds that are already open and require cleaning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The nurse’s first priority should always be to assess the patient’s condition. In the context of NPWT, this means checking for any complaints or problems in the wound area. This assessment helps to ensure that the NPWT is not causing additional issues and that the wound is healing as expected.
Choice B rationale
While it is important to check the settings on the NPWT unit to ensure it is functioning correctly, this is not the first priority. The patient’s well-being and response to treatment take precedence over equipment checks.
Choice C rationale
Documentation is a critical part of patient care, but it comes after patient assessment and any necessary interventions. It serves to record the patient’s status and the care provided but is not the immediate priority.
Choice D rationale
Observing the dressing area is part of the overall assessment of the patient and the effectiveness of the NPWT. However, it is not the first action to take. The nurse must first assess the patient for any discomfort or complications before focusing on the dressing itself.
Correct Answer is D
Explanation
Choice A rationale
Prolonged immobility can indeed cause swelling due to fluid accumulation; however, it typically does not lead to sudden worsening or significant swelling at a specific wound site. It is more associated with generalized edema, particularly in dependent areas of the body.
Choice B rationale
While infections can cause swelling, they are also accompanied by other signs such as redness, warmth, pain, and possibly fever. Swelling alone, without these other symptoms, is less indicative of an infection.
Choice C rationale
A deeper injury might cause swelling, but this would have been identified during the initial assessment. Swelling that occurs later in the healing process is less likely to be from a deeper, previously unnoticed injury.
Choice D rationale
Swelling at a wound site is often due to inflammation, where blood vessels dilate and become more permeable, allowing plasma to leak into the tissue. This is a normal part of the healing process as the body brings in necessary cells and substances to promote recovery.
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