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
Cerebrospinal fluid (CSF) does not produce cerebral neurotransmitters. Neurotransmitters are produced by neurons in the brain and nervous system.
Choice B rationale
CSF provides a protective barrier to some extent, but its primary function is not to act as a barrier to bacteria. The blood-brain barrier primarily serves this function.
Choice C rationale
CSF helps maintain a stable environment in the central nervous system but is not primarily an insulator for maintaining constant temperature. Its thermal properties are secondary.
Choice D rationale
The primary function of CSF is to cushion and protect the brain and spinal cord from mechanical injury. It also helps maintain the brain's buoyancy and provides a stable environment for the central nervous system.
Correct Answer is A
Explanation
Choice A rationale
Scoliosis is identified by a lateral curve of the spine, resulting in uneven shoulders and prominent scapula when bending forward. These physical findings are characteristic of scoliosis, aiding its diagnosis.
Choice B rationale
Muscular dystrophy causes symmetrical muscle weakening, not the asymmetry of scoliosis. It does not present with the specific spinal curvature described.
Choice C rationale
Kyphosis involves a rounded upper back, not a lateral spinal curve. It leads to a hunched posture rather than the shoulder and scapula asymmetry seen in scoliosis.
Choice D rationale
Lordosis is characterized by an exaggerated inward curve of the lower back, not affecting shoulder and scapula symmetry as in scoliosis. It primarily involves the lumbar spine, not causing the described physical findings.
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