A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

Removing excess drainage and wet tissue to prevent maceration of surrounding skin

Stimulating the wound bed to promote the growth of granulation tissue

Removing purulent drainage from the wound bed in order to accurately assess it

Removing dead or infected tissue to promote wound healing

Answer and Explanation

The Correct Answer is D

Choice A rationale: Removing excess drainage and wet tissue to prevent maceration is more related to wound care than debridement.
Choice B rationale: Stimulating the wound bed to promote the growth of granulation tissue is a goal of debridement.
Choice C rationale: Removing purulent drainage from the wound bed is more related to wound care than debridement.
Choice D rationale: The primary goal of debridement is to remove dead or infected tissue to promote wound healing and create an environment conducive to tissue regeneration.

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Correct Answer is A

Explanation

Choice A rationale: The absence of bowel sounds on post-operative day 2 may indicate paralytic ileus, which is a temporary impairment of bowel motility. Paralytic ileus can last for 3-5 days postoperatively and is considered a normal response to surgery.
Choice B rationale: It is not normal for all post-op patients to have absent bowel sounds on day 2. Bowel sounds should typically return within the first 24 hours after surgery.
Choice C rationale: The absence of bowel sounds can be a normal finding in the immediate postoperative period, especially within the first 24 hours. However, it becomes abnormal if prolonged.
Choice D rationale: Documenting absent bowel sounds is appropriate, but notifying the physician should be based on the overall clinical picture and other symptoms.

A. A client 92 years of age who uses a walker, is incontinent, and has an extensive cardiac history B. A client 45 years of age who has paraplegia C. A client 68 years of age who is comatose due to a traumatic brain injury D. A client 75 years of age who uses a cane and has dementia

Correct Answer is A

Explanation

Choice A rationale: The client who is 92 years old, uses a walker, is incontinent, and has an extensive cardiac history is at higher risk for the development of pressure injuries due to age, immobility, and additional risk factors.
Choice B rationale: A client with paraplegia may be at risk for pressure injuries, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
Choice C rationale: A comatose client with a traumatic brain injury is at risk, but other factors in Choice A contribute to a higher overall risk.
Choice D rationale: A client who uses a cane and has dementia may be at risk, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.

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A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

Correct Answer is A

Explanation

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

Correct Answer is A

Explanation

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