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.

Answer and Explanation

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.

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

Explanation

Choice A rationale

Tachycardia is not a symptom of Cushing's triad; it is often associated with other conditions such as stress or heart problems.

Choice B rationale

Bradypnea is a hallmark of Cushing's triad, indicating decreased respiratory rate due to increased intracranial pressure.

Choice C rationale

Hypertension is a key component of Cushing's triad, caused by increased intracranial pressure leading to elevated blood pressure.

Choice D rationale

Bradycardia, or a slower than normal heart rate, is a symptom of Cushing's triad, resulting from increased pressure in the brain affecting the heart rate.

Choice E rationale

Pupillary constriction is not typically associated with Cushing's triad; it is usually related to other neurological conditions.

A. Improve the school hygiene. B. Insist that everyone who is infested with lice follows the prescribed treatment. C. Wash clothing and vacuum furniture, bedding, and carpets. D. Perform hair inspection.

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

Explanation

Choice A rationale

Improving school hygiene is essential for overall health but is not a direct method for preventing and controlling an outbreak of pediculosis. Lice infestations require specific targeted actions to be effectively managed, such as treating those infested and cleaning their belongings.

Choice B rationale

Insisting that everyone who is infested with lice follows the prescribed treatment is crucial for controlling the outbreak. Effective treatment eradicates lice and prevents their spread to others. Consistency in following the prescribed regimen is essential for successful management.

Choice C rationale

Washing clothing and vacuuming furniture, bedding, and carpets are vital steps in controlling lice outbreaks. Lice can survive on these items, leading to reinfestation. Thorough cleaning removes lice and their eggs, helping to prevent the spread and recurrence of infestation.

Choice D rationale

Performing hair inspection helps identify individuals who are infested with lice. Early detection allows for prompt treatment, which is critical in preventing the spread of lice to others. Regular inspections are a proactive measure in managing and controlling outbreaks.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client with head trauma will be monitoring the client for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

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

Explanation

A nurse employed in a school suspects an outbreak of pediculosis. Which of the following nursing actions should be taken to prevent and control the outbreak?

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

Explanation

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