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.

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Correct Answer is B

Explanation

Choice A reason: A history of hypothyroidism is not a contraindication for magnet therapy. Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone, but it does not interfere with the use of magnetic fields. Therefore, patients with hypothyroidism can safely use magnet therapy.

Choice B reason: Having a pacemaker is a significant contraindication for magnet therapy. Magnetic fields can interfere with the functioning of pacemakers, potentially leading to serious complications. Patients with pacemakers should avoid magnet therapy to prevent any risk of device malfunction.

Choice C reason: A history of narcolepsy is not a contraindication for magnet therapy. Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness, but it does not interact with magnetic fields. Therefore, patients with narcolepsy can use magnet therapy without concern.

Choice D reason: An indwelling catheter is not a contraindication for magnet therapy. Indwelling catheters are used for urinary drainage and do not interact with magnetic fields4. Patients with indwelling catheters can safely undergo magnet therapy.

A. Urinary tract infection B. Deep vein thrombosis C. Constipation D. Atelectasis

Correct Answer is D

Explanation

Choice A Reason:

Urinary tract infections (UTIs) are typically caused by bacteria entering the urinary tract. While strict bed rest can increase the risk of UTIs due to factors like catheter use and reduced mobility, the use of an incentive spirometer does not directly prevent UTIs. Instead, preventing UTIs involves maintaining good hygiene, ensuring adequate fluid intake, and, if necessary, using catheters properly.

Choice B Reason:

Deep vein thrombosis (DVT) is a condition where blood clots form in the deep veins, usually in the legs. This can occur due to prolonged immobility, such as strict bed rest after surgery. Preventing DVT involves measures like using compression stockings, administering anticoagulant medications, and encouraging leg exercises. An incentive spirometer, which is used to improve lung function, does not directly prevent DVT.

Choice C Reason:

Constipation is a common issue for patients on bed rest due to reduced physical activity and changes in diet. Preventing constipation involves ensuring adequate hydration, providing a high-fiber diet, and encouraging as much physical activity as possible. The use of an incentive spirometer, which focuses on respiratory function, does not directly address constipation.

Choice D Reason:

Atelectasis is a condition where the alveoli in the lungs collapse, leading to reduced or absent breath sounds in the affected areas. This is a common postoperative complication, especially in patients on strict bed rest, due to shallow breathing and reduced lung expansion. The use of an incentive spirometer encourages deep breathing and helps to keep the alveoli open, thereby preventing atelectasis. This is why the incentive spirometer is an essential tool for postoperative respiratory care.

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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 client wants to start doing magnet therapy. The nurse should explain to the client, which would be a contraindication for the use of magnet therapy?

Correct Answer is B

Explanation

A nurse is caring for a client who will be placed on strict bed rest after surgery. The nurse should educate the client on the use of an incentive spirometer. The use of an incentive spirometer would prevent which postoperative complication?

Correct Answer is D

Explanation

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