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 ["C","D"]
Explanation
Choice A rationale
The trigeminal nerve is responsible for facial sensation and motor functions like chewing, not related to gag reflex impairment.
Choice B rationale
The facial nerve controls facial expressions, taste sensations, and other functions but does not influence the gag reflex.
Choice C rationale
The glossopharyngeal nerve (cranial nerve IX) plays a crucial role in the gag reflex as it innervates part of the pharynx and is responsible for sensory functions in the throat.
Choice D rationale
The vagus nerve (cranial nerve X) also contributes to the gag reflex, providing motor innervation to the pharyngeal muscles and aiding in swallowing and speech functions.
Correct Answer is A
Explanation
Choice A rationale
Potassium-rich foods, such as bananas and potatoes, are recommended for clients with prolonged diarrhea to replace lost electrolytes and maintain normal cellular function.
Choice B rationale
High-fat foods are not recommended for clients with prolonged diarrhea, as they can exacerbate symptoms and are difficult to digest.
Choice C rationale
High-fiber foods may worsen diarrhea by increasing stool bulk and frequency.
Choice D rationale
While protein-rich foods are important, they do not specifically address the electrolyte imbalances caused by prolonged diarrhea.
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