A nurse is assessing a client with a pressure ulcer on the sacrum. Which of the following factors would increase the risk of infection in the wound?

The presence of necrotic tissue

The use of hydrocolloid dressing

The frequency of wound irrigation

The application of topical antibiotics

Answer and Explanation

The Correct Answer is A

Answer: A.

The presence of necrotic tissue increases the risk of infection by providing a medium for bacterial growth and impairing wound healing. Necrotic tissue should be debrided to promote wound healing.

B. The use of hydrocolloid dressing is not a risk factor for infection. Hydrocolloid dressings are occlusive and adhesive, which create a moist environment that facilitates wound healing and prevents bacterial contamination.

C. The frequency of wound irrigation is not a risk factor for infection. Wound irrigation is done to cleanse the wound and remove debris and exudate. It should be done gently and with sterile solution to avoid trauma and contamination.

D. The application of topical antibiotics is not a risk factor for infection. Topical antibiotics are used to treat or prevent infection in some wounds. They should be used with caution and as prescribed, as overuse may lead to resistance or allergic reactions.

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Correct Answer is C

Explanation

Correct answer: C) Ensure that the dressing is sealed and airtight around the wound.

Rationale: Negative pressure wound therapy (NPWT) is a device that applies

subatmospheric pressure to the wound bed, which promotes granulation tissue formation, removes excess fluid and debris, and reduces edema and bacterial colonization. The nurse should ensure that the dressing is sealed and airtight around the wound to maintain negative pressure and prevent air leaks.

Incorrect options:

A) Change the dressing every 12 hours or as needed. - This is not recommended for NPWT, as frequent dressing changes can disrupt wound healing and increase the risk of infection. The nurse should change the dressing every 48 to 72 hours or as prescribed by the provider.

B) Irrigate the wound with normal saline before applying the dressing. - This is not recommended for NPWT, as irrigation can introduce bacteria into the wound and interfere with negative pressure. The nurse should clean the wound with normal saline or sterile water and pat it dry gently before applying the dressing.

D) Clamp the tubing when ambulating or repositioning the client. - This is not recommended for NPWT, as clamping can interrupt negative pressure and cause tissue damage. The nurse should secure the tubing to prevent kinking or dislodgment and keep the device below the level of the wound when ambulating or repositioning the client.

A. To reduce edema and venous pressure B. To increase arterial blood flow and oxygenation C. To prevent infection and inflammation D. To stimulate nerve regeneration and sensation

Correct Answer is A

Explanation

Answer: A

To reduce edema and venous pressure is the rationale for elevating the leg above the level of the heart whenever possible. Venous ulcers are caused by chronic venous insufficiency, which impairs venous return and causes blood pooling, increased venous pressure, and edema in the lower extremities. Elevation helps to facilitate venous return and reduce edema and venous pressure, which improves wound healing.

B. To increase arterial blood flow and oxygenation is not the rationale for elevating the leg above the level of the heart whenever possible. Arterial ulcers are caused by arterial insufficiency, which impairs arterial blood flow and oxygenation to the lower extremities. Elevation may worsen arterial blood flow and oxygenation, as it reduces the effect of gravity on arterial perfusion.

C. To prevent infection and inflammation is not the rationale for elevating the leg above the level of the heart whenever possible. Infection and inflammation are complications of venous ulcers, but they are not directly affected by elevation. Infection and inflammation are prevented by proper wound care, such as cleansing, dressing, debridement, and antibiotic therapy.

D. To stimulate nerve regeneration and sensation doesn’t help with venous ulcers.

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A nurse is assessing a client with a pressure ulcer on the sacrum. Which of the following factors would increase the risk of infection in the wound?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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