A nurse is assessing a client’s wound and notes there is slough present. What would be an appropriate intervention for this wound?

Cover

Clean

Debride

Leave alone

Answer and Explanation

The Correct Answer is C

Choice A reason: Cover

Covering a wound with slough is not an appropriate intervention. Slough is a type of necrotic tissue that can impede the healing process by providing a medium for bacterial growth and preventing the formation of healthy granulation tissue. Simply covering the wound without addressing the slough can lead to infection and delayed healing.

Choice B reason: Clean

Cleaning the wound is a necessary step in wound care, but it is not sufficient on its own to address the presence of slough. While cleaning can help reduce the bacterial load and remove some debris, it does not effectively remove the slough itself. Slough often requires more targeted interventions such as debridement to be effectively managed.

Choice C reason: Debride

Debridement is the most appropriate intervention for a wound with slough. Debridement involves the removal of necrotic tissue, including slough, to promote a clean wound bed and facilitate the healing process. There are several methods of debridement, including autolytic, enzymatic, mechanical, and surgical, each with its own indications and benefits. Removing the slough allows for better assessment of the wound and promotes the formation of healthy granulation tissue.

Choice D reason: Leave Alone

Leaving a wound with slough alone is not advisable. Slough can harbor bacteria and impede the healing process, leading to chronic wounds and potential infection. Without intervention, the wound is unlikely to progress through the normal stages of healing.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A Reason:

Open the client’s visual acuity using a Snellen chart is incorrect. This action assesses cranial nerve II (optic nerve), which is responsible for vision. The Snellen chart is used to measure visual acuity, not the function of cranial nerve VI

Choice B Reason:

Whisper none of the client’s ears while blocking the other is incorrect. This action assesses cranial nerve VIII (vestibulocochlear nerve), which is responsible for hearing and balance. Whispering tests the auditory function of this nerve.

Choice C Reason:

Ask the client to inspect up is correct. Cranial nerve VI (abducens nerve) controls the lateral rectus muscle, which is responsible for moving the eye outward. Asking the client to look up and outward helps assess the function of this nerve.

Choice D Reason:

Ask the client to smile is incorrect. This action assesses cranial nerve VII (facial nerve), which controls the muscles of facial expression. Smiling tests the motor function of this nerve.

A. Pee privacy B. Otoscope C. Tannic acid D. Pupil dilation

Correct Answer is ["A"]

Explanation

Choice A reason: Pee privacy

Ensuring privacy for a patient, especially one who is pregnant, is crucial. Privacy helps maintain the patient’s dignity and comfort during medical procedures. It also fosters a trusting relationship between the patient and the healthcare provider. In this context, “Pee privacy” likely refers to ensuring the patient has privacy when providing a urine sample, which is a common procedure during pregnancy check-ups to monitor for conditions like gestational diabetes or preeclampsia.

Choice B reason: Otoscope

An otoscope is a medical device used to look into the ears. While it is an essential tool in many medical examinations, it is not specifically related to the care of a pregnant patient unless there is a specific concern about ear health. Therefore, this choice is less relevant in the context of routine pregnancy care.

Choice C reason: Tannic acid

Tannic acid is a substance that can be used for various medical purposes, including treating burns and stopping bleeding. However, it is not typically associated with routine pregnancy care. Its inclusion in this list seems out of place unless there is a specific, unusual medical condition being addressed.

Choice D reason: Pupil dilation

Pupil dilation is a procedure often performed during eye examinations to allow a better view of the retina and other structures inside the eye. While important in ophthalmology, it is not a standard procedure in the care of a pregnant patient unless there is a specific concern about the patient’s vision or eye health.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client’s wound and notes there is slough present. What would be an appropriate intervention for this wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?

Correct Answer is C

Explanation

A nurse is caring for a patient who is pregnant. Check the name tag (select all that apply):

Correct Answer is ["A"]

Explanation

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which action should the nurse take?

A nurse on the medical-surgical unit is conducting a fall risk assessment on four clients. Which of these clients would be at greatest risk for falls?

A nurse is teaching a class about palliative care. The nurse should include that which of the following is the focus of palliative care?

A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. After stopping the transfusion, which intervention is important to complete FIRST?

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse positions the client in the orthopneic position. What is the primary reason for the use of this position for this client?

A nurse is caring for a client who had an arterial blood gas drawn. The pH on the ABG is 7.10. What acid-base imbalance does this client have?

A client has an injury to the left ankle requiring partial weight bearing. The client is elderly with a history of balance deficit. Which assistive device would be most appropriate for this client?