When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage.
Which intervention(s) should the nurse implement? Select all that apply.

Document the wound measurements with tunneling.

Cleanse the wound and discontinue the VAC system.

Increase the wound VAC suction to eliminate the drainage.

Consult the wound care specialist to evaluate the wound.

Reapply the VAC system after irrigating away drainage.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

Documenting the wound measurements with tunneling is important for tracking the wound's progression and planning appropriate interventions. Accurate documentation helps in assessing the effectiveness of the treatment plan.

Choice B rationale

Cleansing the wound and discontinuing the VAC system is necessary when foul, purulent drainage is observed. This action helps to prevent further infection and allows the healthcare provider to reassess the wound care approach.

Choice D rationale

Consulting the wound care specialist to evaluate the wound is essential for expert advice on managing complex wounds. Specialists can provide tailored recommendations to promote wound healing and prevent complications.

Choice C rationale

Increasing the wound VAC suction to eliminate the drainage is not appropriate as it may worsen the infection or damage the surrounding tissues. Proper wound care protocols should be followed to ensure safe and effective treatment.

Choice E rationale

Reapplying the VAC system after irrigating away drainage is not advisable if there is evidence of infection. The wound should be thoroughly assessed, and appropriate measures should be taken to address the underlying infection.

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Correct Answer is ["B","C"]

Explanation

Choice A rationale

The nurse’s signature on the surgical consent form does not verify the client’s understanding of the procedure. This responsibility lies with the physician or surgeon, who must ensure that the client is fully informed about the nature, risks, benefits, and alternatives of the procedure. The nurse’s role is to witness the client’s signature, confirming that the client has signed the form without coercion and is competent to do so.

Choice B rationale

The client’s competence to sign the consent form is a crucial aspect that the nurse witnesses. By signing as a witness, the nurse attests that the client is mentally sound and capable of making informed decisions about their medical care. This includes verifying that the client is not under the influence of substances that could impair judgment and that they understand the nature of the consent they are giving.

Choice C rationale

The client voluntarily granting permission for the procedure is another key element of the nurse’s witnessing role. The nurse’s signature confirms that the client has signed the consent form of their own free will, without any undue pressure or coercion. This ensures the validity of the consent and protects the client’s rights and autonomy in making healthcare decisions.

Choice D rationale

The explanation of the procedure, its necessity, and potential outcomes are the responsibility of the surgeon or physician. The nurse does not provide this detailed explanation but ensures that the client has had the opportunity to receive this information from the appropriate healthcare provider. The nurse’s signature does not verify that the surgeon has explained the procedure; it simply confirms the witnessing of the client’s signature.

Choice E rationale

Understanding the risks and benefits of the procedure is part of the informed consent process, which the physician or surgeon must explain to the client. The nurse’s role is to witness the client’s signature, ensuring that the client has had the opportunity to receive this information. The nurse’s signature does not confirm the client’s understanding of these details but indicates that the consent was signed voluntarily and competently.

A. pH 7.36. B. Partial pressure of oxygen (PaO2) 82 mm Hg. C. Partial pressure of carbon dioxide (PaCO2) 38 mm Hg. D. Bicarbonate (HCO3-) 24 mEq/L (24 mmol/L).

Correct Answer is ["A","B","C","D"]

No explanation

View Question and Answer

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When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is the legal implication of the nurse's signature on the client's surgical consent form? Select all that apply.

Correct Answer is ["B","C"]

Explanation

Which of the following values are within normal limits?

Correct Answer is ["A","B","C","D"]

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When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage.
Which intervention(s) should the nurse implement? Select all that apply.