A client's orders include a wound dressing using an autolytic debriding agent. The nurse providing discharge instructions to the client should include which statement?
Keep the dressing very wet at all times.
Do not use a dressing 6 hours/day.
Cleanse the wound with Dakin's solution.
The wound may have a foul odor.
The Correct Answer is D
Choice A rationale
Keeping the dressing very wet at all times is not advisable with autolytic debriding agents. Excess moisture can cause maceration of the surrounding skin and increase the risk of infection. The dressing should maintain an optimal level of moisture to promote autolysis without causing harm.
Choice B rationale
Not using a dressing for 6 hours/day is incorrect advice. Continuous application of the dressing is essential for the autolytic process. Removing the dressing for extended periods disrupts the environment needed for autolysis, delaying wound healing.
Choice C rationale
Cleansing the wound with Dakin's solution is not recommended with autolytic debridement. Dakin's solution is a chemical debriding agent, and its use can interfere with the natural autolytic process. It is better to use saline or appropriate cleansers as directed.
Choice D rationale
The wound may have a foul odor due to the autolytic debridement process. As dead tissue is broken down, it can produce a distinct odor. Educating the client about this expected outcome helps them understand that it is a normal part of the healing process and not necessarily a sign of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Necrosis is the death of body tissue and can result from various factors, including pressure ulcers, but it is not the direct cause of pressure ulcers.
Choice B rationale
Low capillary pressure is not a direct cause of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin, leading to reduced blood flow and tissue damage.
Choice C rationale
Increased mobility is not a cause of pressure ulcers. In fact, decreased mobility or immobility is a significant risk factor for developing pressure ulcers.
Choice D rationale
Extrinsic factors, such as prolonged pressure, friction, and shear, are the primary causes of pressure ulcers. These factors lead to reduced blood flow, tissue ischemia, and ultimately, tissue damage.
Correct Answer is C
Explanation
Choice A rationale
Increased intracranial pressure can result from various conditions, including brain injuries, tumors, or infections. However, decerebrate posturing is specifically associated with brain stem dysfunction rather than increased intracranial pressure alone.
Choice B rationale
Dysfunction in the cerebrum can lead to different posturing responses, such as decorticate posturing, which involves abnormal flexion of the arms. Decerebrate posturing, on the other hand, indicates more severe damage lower in the brain stem.
Choice C rationale
Dysfunction in the brain stem is indicated by decerebrate posturing, which involves extension and outward rotation of the arms and legs in response to painful stimuli. This type of posturing signifies serious damage to the brain stem and carries a poor prognosis.
Choice D rationale
Dysfunction in the spinal column may result in various neurological deficits but does not specifically cause decerebrate posturing. This type of posturing is indicative of brain stem damage rather than spinal column issues.
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